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Based on review of the facility Emergency Plan, record review and staff interview, it was determined, the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on community-based risk assessment poses a potential risk and may cause harm to the patients and staff during an emergency, if specific needs of both the patient and staff are not identified as part of the EP plan.

Findings include:


Observations made during document review made on April 18, 2023revealed the facility failed to obtain a community-based risk assessment and use it to develop a facility based risk assessment prior to developing the facility's emergency plan

Employees #1 and #51 confirmed during the exit conference that the facility did not obtain a community based risk assessment and use it to create the facilities Emergency Plan.

Based on record review and staff interview, it was determined the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population which includes delegation of authority and succession plans may cause disruption of services to patients/clients during an emergency which could lead to harm.

Findings include:

Observation during review April 18, 2023revealed .The facility was unable to locate any documentation addressing the needs of the patient population within the current written plan. Additionally the facility did not have a succession plan that would be used for emergency operation that also included the required delegation of authority.

Employees #1, and #51confirmed during the exit conference that the facility was unable to locate any documentation addressing the needs of the patient population or a succession plan with delegation of authority within the current written plan.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined, the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. and created policies that were not risk based. The facility also failed to have policies for the requited CMS hazards Failure to develop emergency plans based on a facility-based risk assessments may cause harm to the patients and staff during an emergency.

Findings include:

Observation during document review on April 18, 2023 revealed their plans policies provided, were not based on a current risk assessment. CFR 494.62 requires both facility and community hazard assessments but used to develop the policy and procedures. The policies also are required to address extreme temperatures and emerging infectious diseases.

Employees #1, and #51 confirmed during the exit conference the facility did not have a copy of the community-base risk assessment to provide proof it was used to create the policies and procedures and did not contain policies for extreme temperatures or emerging infectious diseases.

Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to develop and implement emergency preparedness policies and procedures, based on subsistence needs for staff and patients. Failure to develop subsistence needs for staff and patients during an emergency could cause harm to staff and patients if immediate needs like food, water, medical and pharmaceutical supplies and alternate sources of energy are not planned for and available.


Finding include

During observations while on tour April18, 2023, it was revealed that the facilities did not have the needed amounts of water or food needed to sustain the staff patients and visitor the three days as described in their plan.

Employees # 1, and #51 confirmed during the exit interview conducted on Aug 15, 2022, that the sustenance on hand was not nearly enough.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined the facility failed to develop and implement a policy and procedure for the use of volunteers in an emergency. Failure to address the use of volunteers in an emergency could adversely impact patient care during an emergency and lead to potential harm..

Findings include:

During document review on April 18, 2023, it was revealed the facility's Emergency Plan (EP) did not include policies and procedures to address the use of volunteers in an emergency.

Employee #1 and #51 confirmed during an interview that the facility EP did not include policies and procedures to address the use of volunteers in an emergency.

Based on review of the Emergency Plan (EP), facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policy and procedure at alternative care sites may cause harm to the residents during an emergency.

Findings include:

During document review on April 18, 2023, it was revealed the facility's Emergency Plan related to the section which addresses policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Employee #1 and #51 confirmed during document review that the facility EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Based on record review and interview it was determined the facility did not have documentation in the emergency preparedness communication plan that complies with Federal, State and local laws that included a method for sharing information. Failure to have a means to share private information to assist in patient care could result in miss information being provided to other providers providing care for the facility's patients.

Findings include:

Observations found during the document review process conducted on April 18, 2023 of the facility's Emergency Plan did not include policies and procedures, in the communication plan for the following:
1. Sharing information and medical documentation for patients under the facility's care, as
necessary, with other health care providers to maintain the continuity of care.
2. A means, in the event of an evacuation, to release patient information as permitted under 45
CFR 164.510.
3. A means of providing information about the general condition and location of patients under the
facility's care as permitted under 45 CFR 164.510.


Employees #1, and #51 confirmed during the exit conference that the facility did not identify a method for sharing information and medical documentation for patients under the facilities care as necessary and develop policy and procedures that address the means the facility will use to release patient information to include the general condition and location of patients.

Based on review of the Emergency Plan (EP), record review, and staff interview, it was determined the facility failed to develop a means for sharing information on occupancy/needs, and it's ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in patients not receiving care and services as needed.


Findings include:

Observations during EP review on April 18, 2023, revealed the facility's Emergency Plan documentation related to requirements for a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center did not include a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

Employee #1 and #51 confirmed during the exit interview that the EP plan for the facility did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

Based on review of the facility's emergency plan and staff interview, it was determined the facility failed to have the new and existing staff review the emergency preparedness plan. Failure to have staff review the emergency preparedness plan consistent with their expected roles may cause harm to the residents and/or staff during an emergency.

Findings include:

Observations, interview and record review made on April 18, 2023, revealed the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures. In addition, the staff was questioned nobody was able to find the emergency preparedness policies or phone numbers of required numbers. The staff was not familiar the emergency Preparedness program and didn't recall receiving any training. The management was able to find their EP program.

Employee #1 and #51 confirmed during the exit interview the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures.

Based on review of the facility's Emergency Preparedness Testing Requirements, record review and staff interview, it was determined the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency.


Findings include:

During document review on April 18, 2023, it was revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based and a Facility- based or table top drills for the last two cycles.

Employee #1 and #51 confirmed during the exit interview that the facility was not able to locate proof of participation in a full-scale exercise that was community-based or a facility based exercise in the last four years.

Based on observation it was determined that the wqll seperating the hospital from the outpatient treatment center did not have have the 2 hour required fire rating to not resist the passage of fire or smoke. Failing to protect resident sleeping rooms from heat or smoke could cause harm or death to the patients and staff.

18.1.3.4 Contiguous Non-Health Care Occupancies. 18.1.3.4.1 *
Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by construction having a minimum 2-hour fire resistance rating, and the facility is not intended to provide services simultaneously for four or more inpatients who are incapable of self preservation.

Findings include:

Observations while on tour on April 17-18, 2023, revealed that the wall between the outpatient treatment center (OTC) and the hospital premise did not meet the two hour rated fire wall seperation. The wall did exist but not extend from floor to roof deck and it was not shown to have the correct rating on the drawings.

Employees #1 and #51 confirmed the lack of a two hour fire rating for the wall between the OTC and the hospital

( Condition Level ) Based on observations the facility failed to maintain a safe and reliable means of exit by not allowing a pathway for patients to exit in an emergency. Failure to maintain a clear and obstruction-free pathway can cause death or injury when a rapid exit is needed.

NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:
1. Locks complying with 19.2.2.2.5 shall be permitted.
2. Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.
3. Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
4. Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted.
5. Approved existing door-locking installations shall be permitted.
19.2.2.2.5 Door-locking arrangements shall be permitted in accordance with either 19.2.2.2.5.1 or 19.2.2.2.5.2.
19.2.2.2.5.1 Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
19.2.2.2.5.2 Door-locking arrangements shall be permitted where patients' special needs require specialized protective measures for their safety, provided that all of the following are met:
1. Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
2. A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
3. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7.
4. The locks are electrical locks that fail safely so as to release upon loss of power to the device.
5. The locks release by independent activation of each of the following:
a. Activation of the smoke detection system required by 19.2.2.2.5.2(2)
b. Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3).

19.2.2.2.6 Doors that are located in the means of egress and are permitted to be locked under other provisions of 19.2.2.2.5 shall comply with all of the following:
1. Provisions shall be made for the rapid removal of occupants by means of one of the following:
a. Remote control of locks
b. keying of all locks to keys carried by staff at all times
c. Other such reliable means available to the staff at all times
2. Only one locking device shall be permitted on each door.
3. More than one lock shall be permitted on each door, subject to approval of the authority having jurisdiction

Findings include:

Observation while on tour April 17-18, 2023, revealed the exit doors from the facility are being held shut by the magnet and on four different doors an additional deadbolt. The door magnets are not connected to the fire alarm and the deadbolts were not approved by the authority having jurisdiction. Staff had a key to the deadbolts and electronic badges to access the door. The maintenance team had the deadbolts removed from the doors in question when brought to their attention. One of the three exits required staff to open two doors and a steel fence gate to escape from the lockdown area.

Employees #1 and #51 confirmed the door magnets were not hooked up to the fire alarm system and the secondary locks were not approved by the authority having jurisdiction.

Based on observation and record review the facility failed to conduct testing to confirm the emergency light in the facility was tested to confirm the lights would operate in a loss of power to the facility. Failing to test the emergency lighting could result in failure when the power goes out which could result in injury to staff and patients

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. , for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1. (2) The Test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.( 3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery-powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction

Findings include:

Findings during the document review on April 18, 2023 revealed the facility was conducting annual testing of the emergency lights in the facility. The facility staff was not able to provide documented proof the facility conducted monthly tests of the emergency lighting.

Employees number #1 and #51 confirmed they did not have documented proof they were conducting monthly testing of the emergency lights.

( Condition Level ) Based on observation the facility failed to maintain the fire alarm in operational condition. Failure to maintain the fire alarm panel can result in a fire going unnoticed and could potentially result in the death or injury of the staff or patients in the building.

NFPA 101: Life Safety Code, 2012 Edition - Chapter 9 Building Service and Fire Protection Equipment.
9.6.1.6 * Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings include:

Observations while on tour April 17-18,2023, revealed the fire alarm panel in the facility was in alarm status but had been silenced. Employee #51 reported the panel had gone into alarm the day before more than twenty-four hours prior but no fire was found the fire department was canceled and the panel was put in silence mode but not reset. The facility is required to initiate a fire watch until the fire alarm panel is restored to normal condition. The system was reset and was able to be restored to normal condition once noticed. In addition, the fire department is required to be notified as well as the alarm company and insurance company since the sprinkler system would not have been able to send an alarm condition to the alarm company.

Employees #1 and #51 confirmed during the exit interview that the panel was in alarm and unable to receive fire indication/transmit to the alarm company and no fire watch was established or notifications made to the required entities.

Based on record review and interview the facility failed to provide required sprinkler inspections. Failing to inspect test and maintain the sprinkler system could cause the system to be inoperable due to lack of maintenance during a fire and could cause harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "5.4.2 * Dry Pipe Systems. Dry pipe systems shall be kept dry at all times.
5.4.2.1 During nonfreezing weather, a dry pipe system shall be permitted to be left wet if the only other option is to remove the system from service while waiting for parts or during repair activities.
5.4.2.2 Refrigerated spaces or other areas within the building interior where temperatures are maintained at or below 40°F (4.4°C) shall not be permitted to be left wet.
5.4.2.3 Air driers shall be maintained in accordance with the manufacturer's instructions.
5.4.2.4 Compressors used in conjunction with dry pipe sprinkler systems shall be maintained in accordance with the manufacturer's instructions.
5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Table 5.1.1.2 Summary of Sprinkler System Inspection, Testing, and Maintenance
Gauges (dry, preaction, and deluge systems) Weekly 5.2.4.2, 5.2.4.3, 5.2.4.4

Findings include:

Based on record review and interview on April 18, 2023, revealed the facility failed to provide documentation for weekly sprinkler gauge inspections and monthly isolation valve inspections for the last three years.

Employees #1 and #51 confirmed during the exit conference that the facility failed to provide documentation for weekly sprinkler gauge inspections and monthly isolation valve inspections for the last three years.

Based on observation it was determined the facility failed to fill penetrations in the electrical room walls where conduits passed through. Failing to seal the penetrations, holes and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients during time of a fire.



NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations while on tour April 17-18, 2023, revealed the that facility had holes in the firewall in the following locations:

1. Numerous pipes and conduits had missing or shrunken fire caulking in the main electrical room in the main hallway.
2. The fire door sperating the hallway and the electricsl room was held open by a door stop.

Employees # 1 and # 51 confirmed during the exit interview conducted April 18, 2023, that the separating wall in the electrical room had penetration in the wall that was not filled with a material capable of restricting the transfer of smoke or fire.

Based on the record review the facility failed to conduct required Damper testing. Failure to conduct damper testing could result in the failure of the dampers which would allow the firewalls to become inoperable which could result in the death of patients or staff in the event of a fire.

NFPA 101: Life Safety Code, 2012 Edition - Chapter 8 Features of Fire Protection
8,5,5,4,2 Smoke dampers and combination fire and smoke dampers required by this Code shall be inspected, tested, and maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 80: Standard for Fire Doors and Other Opening Protectives, 2010 Edition - Chapter 19 Installation, Testing, and Maintenance of Fire Dampers.
19.3.3 Inspection. Following completion of the test, a visual inspection shall be made of the assembly to ensure no obstructions have been introduced.
19.3.4 Documentation. All inspections and testing shall be documented, indicating the location of the fire damper, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. 19.4 * Periodic Inspection and Testing.
19.4.1 Each damper shall be tested and inspected 1 year after installation.
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.

Findings include:

.Observation during document review on April 18, 2023, showed the facility did not have records to show the facility had conducted the required damper testing in the last six years.

Employees number #1, and #51 during the exit the facility did not have the required records showing damper testing in the last 6 years.

Based on record review and staff interview the facility failed to provide fire drill documentation for several years of the required fire drills. Failing to conduct the fire drills in accordance with the life safety code to familiarize staff with condition s under an actual fire can result in harm to patients and staff during an actual fire or emergency situation.

NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.7.2.2 written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Emergency phone call to the fire department
4. Response to alarms
5. Isolation of fire
6. Evacuation of immediate area
7. Evacuation of smoke compartment
8. Preparation of floors and building for evacuation
9. Extinguishment of fire.

Findings include:

Based on a record review and staff interview on April 18, 2023, the facility failed to provide documentation for 2022, and 2023.

During the exit conference conducted on April 18, 2023, the above findings were again Confirmed by Employees #1 and #51.

Based on interview it was determined the facility was not performing the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's ". Failing to inspect and test fire-rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code.

NFPA 80 Section 5.2* Inspections Section 5.2.1* Fire door assemblies shall be inspected and tested not less than annually , and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 Horizontal sliding , Vertically Sliding, and Rolling Doors.
Section 5.2.14.3 All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation.

Findings include:

Observation while performing a document review on April 18, 2023, revealed the facility did not have written records of the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's.

Employees#1 and #51 confirmed during the exit conference on April 18, 2023, that the facility did not have written records of the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's.

Based on record review and interview with staff, it was determined that the facility failed to conduct, maintain and document electrical receptacle testing in all patient care areas annually throughout the facility. Failing to test and document annually the receptacle testing of all patient care areas of the facility could lead to an ignition hazard in a patient care area potentially causing a fire and or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction." NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.3 "Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months."
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Findings include:

Observation during the paperwork review on April 18, 2023, revealed that there was no documentation to review for receptacle testing in patient care areas

Employees #1 and #51 confirmed during the exit conference that there was no documentation to review for receptacle testing in patient care areas.

Based on observation the facility did not have a means to monitor the emergency generator for potential problems that might prevent it from operating correctly. Failure to monitor the emergency generator when needed could cause the generator to fail and result in death or injury to staff and patients.

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 6 Electrical Systems
6.4.1.1.17 Alarm Annunciator.
A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
1. Individual visual signals shall indicate the following:
a. When the emergency or auxiliary power source is operating to supply power to load
b. When the battery charger is malfunctioning
2. Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
a. Low lubricating oil pressure
b. Low water temperature (below that required in 6.4.1.1.11)
c. Excessive water temperature
d. Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
e. Overcrank (failed to start)
f. Overspeed

Findings include:

Observation while on tour April 17-18, 2023, revealed the facility did not have a remote annunciator that is storage battery powered for monitoring potential problems with the emergency generator. The facility was equipped with a blue light that would flash when the generator started.

Employees #1 and #51 confirmed at the exit conference that the facility did not have a remote panel to monitor the emergency generator for potential problems as described in NFPA 99

Based on observation the facility installed the emergency generator without a backup fuel source in a rural area of the state. not having a backup source of fuel in a rural area could result in loss of power to the hospital and possible injury or death to the patients

NFPA 110: Standard for Emergency and Standby Power Systems, 2022 Edition - Chapter 5 Emergency Power Supply (EPS): Energy Sources, Converters, and Accessories
5.1 Energy Sources.
5.1.1 General. The following energy sources shall be permitted to be used for the emergency power supply (EPS):
1 Liquid petroleum products at atmospheric pressure as specified in the applicable ASTM standards and as recommended by the engine manufacturer
2 Liquefied petroleum gas (liquid or vapor withdrawal) as specified in the applicable ASTM standards and as recommended by the engine manufacturer
3 Natural or synthetic gas
4 Hydrogen gas
5.1.1.1 For Level 1 installations in locations where the probability of interruption of off-site fuel supplies is high, on-site storage of an alternate energy source sufficient to allow full output of the EPSS to be delivered for the class specified shall be required, with the provision for automatic transfer from the primary energy source to the alternate energy source.
Findings include:
Observation while conducting a survey on April 18, 2023, revealed the emergency generator for the hospital was supplied with natural gas from a remote location. The facility had not conducted a risk assessment to confirm if the probability of interruption of off-site fuel supplies is high. The facility is in a remote location in the state and does not have a backup fuel supply on-site in case an off-site supply is lost.

Employees #1 and #51 confirmed the generator is only supplied by an off-site natural gas system. No risk assessment had been performed.

Based on observation the facility failed to maintain oxygen cylinders in a code-compliant and safe manner. Failure to maintain oxygen in a safe environment could result in jury or death of staff and patients
NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment

11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from
combustibles or materials by one of the following:
1. Minimum distance of 6.1 m (20 ft)
2. Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13
3. Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour
11.3.4 Signs. 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed
on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the
following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED
WITHIN NO SMOKING. 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
1. Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
2. Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
3. Cylinders shall be protected from tampering by unauthorized individuals.
4. Cylinders or cylinder valves shall not be repaired, painted, or altered.
5. Safety relief devices in valves or cylinders shall not be tampered with.
6. Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
7. A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
8. Sparks and flame shall be kept away from cylinders.
9. Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
10. Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1
11. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
12. Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

Finding include:

Observations while on tour April 17-18, 2023, revealed the facility was storing oxygen cylinders in the pharmacy without 5 feet of separation from combustibles or proper labeling of full and empty cylinders or A precautionary sign, readable from a distance of five (5) feet, indicating oxygen storage in the room.

Employees #1 and #51 confirmed during the exit conference that the oxygen was not
being stored correctly per NFPA 99 and 101.

Based on interview and document review the facility failed to provide programs for continuing education and periodic review of safety guidelines and usage requirements for medical gases and oxygen cylinders. Failing to provide training programs and periodic review of safety guidelines for oxygen cylinders or liquid oxygen could cause harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 21, Section 21.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."." NFPA 99 2012 Edition Chapter 11 Section 11.5.2.1" Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.

Findings include:

Observations and document review on April 18, 2023, revealed the facility failed to provide initial and continuing education training with a periodic review of safety guidelines and usage requirements for medical gases and oxygen cylinders.

Employees #1, and #51 confirmed during the exit interview that the facility failed to provide proof of continuing safety education for medical gases.