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Based on record review and interview the facility failed to ensure annual and initial in-service training for new and existing staff, individuals providing on-site services under arrangement, and volunteers on the emergency preparedness plan for 4 (staff D, staff Q, staff R, and staff S) of 12 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and initial in-service training for new and existing staff, volunteers, and individuals providing on-site services under arrangement for the following staff:


Staff D with the date of hire 09/15/16 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff Q with the date of hire 09/08/14 had not received initial or 2015-2017 annual in-service training for the facility emergency preparedness plan.

Staff R with the date of hire 03/10/16 had not received initial in-service training for the facility emergency preparedness plan.

Staff S with the date of hire 11/08/18 had not received initial in-service training for the facility emergency preparedness plan.



The emergency preparedness training records for initial and or annual in-service do not exist for Staff D, Staff Q, Staff R, and Staff S.

On 03/19/19 at 11:17 am the surveyor requested Pawhuska hospital training transcripts of new and existing staff, volunteers, individuals providing on-site services under arrangement.
After review of the requested documentation, the surveyor asked Staff T for the facility process for training on emergency preparedness. Staff T stated the facility provides both initial and annual training for employees related to Emergency Preparedness. The emergency preparedness initial and or annual documentation did not exist for some staff.
Staff T stated the facility would continue to work on the staff training for emergency preparedness.

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing was completed as required.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2016, 2017, and 2018, as the documents do not exist.

On 03/19/19 at 1:52 pm Staff P was asked to provide the annual emergency generator fuel quality testing documentation for 2016, 2017, and 2018. Staff P stated annual emergency generator fuel quality tests have no been done but they will get them done.

Based on observation and interview, the facility failed to ensure each egress access door could be opened with only one action as required.

Findings:

On 03/20/19 at 1:15 pm a padlock was observed on the janitors closet in the pharmacy.

On 03/20/19 at 1:34 pm a deadbolt was observed on X-Ray door 414 with a turn knob on the egress side.

On 03/20/19 at 1:38 pm Staff P was asked why the deadbolt locks were placed on the X-Ray room door, and padlock on the janitor closet in the pharmacy. Staff P stated it may he did not know why the lock was placed on the X-Ray door but the padlock was placed on the janitor's closet because they put expired medications in there. Staff P stated they would take off the locks and make sure appropriate locks that would open with one action would be installed.

Based on observation and interview the facility failed to ensure emergency lighting was tested and installed as required.

Findings:

Record review showed the facility did not document 30 second monthly testing of the battery backed up emergency lighting as required.

On 03/19/19 at 10:20 am Staff P was asked where the documentation is for the testing of the battery backed up emergency lighting testing for 30 seconds. Staff P stated he will start documenting the 30 second per month testing of all battery backed up emergency lighting in their facility.

On 03/20/19 at 2:03 pm no emergency powered lighting was observed at the egress corridor exit outside the CT area or at the CT exit discharge area.

On 03/20/19 at 2:05 pm at the Emergency Room exit discharge no emergency powered lighting was observed to be installed.

On 03/20/19 at 2:05 pm staff P stated they would get battery backed up emergency lighting installed at the CT area and also at the ER area to be in complaince.

Based on observation and interview the facility failed to ensure cooking facilities were protected as required.

Findings:

On 03/20/19 at 2:21 pm observed a Class-K silver fire extinguisher installed in the kitchen but did not have the required placard with the instructions to pull the kitchen UL 300 hood extinguishing system before using the silver Class-K fire extinguisher.

On 03/20/19 at 2:21 pm the surveyor stated to staff P a placard is to be conspicuously placed near each portable fire extinguisher in the cooking area with instructions for staff not to use the fire extinguisher until the cooking hood fire suppression system has been activated per NFPA 96, 2011 Edition, 10.2.2.

On 03/20/19 at 2:21 pm Staff P stated he did not know about the requirement of having placards posted at each fire extinguisher that is installed in the kitchen but will make sure one gets installed at each fire extinguisher.

Based on observation and interview the facility failed to ensure alcohol based hand rub (ABHR) was installed properly.

Findings:

On 03/20/19 at 2:24 pm an ABHR was observed installed over a light switch in the kitchen manager's office.

On 03/20/19 at 2:24 pm the surveyor stated to Staff P that ABHR's are not to be installed over ignition sources and have at least one inch horizontal separation from potential ignition sources.

On 03/20/19 at 2:24 pm Staff P stated he would remove the ABHR and get it installed in an area not over or near an ignition source.

Based on observation and interview the facility failed to ensure automatic sprinkler head spray patterns would not be hindered by objects being installed too close.

Findings:

On 03/20/19 at 12:08 pm the surveyor observed a ceiling light to extend down from the ceiling approximately four and a half inches and was approximately six inches from a sprinkler head located in the biohazard waste hazardous area closet.

On 03/20/19 at 12:08 pm the surveyor stated to staff P with the lighting fixture too close to the sprinkler head it would affect the spray pattern of the sprinkler head and the sprinkler spray pattern would not effectively cover the hazardous area room as required.

On 03/20/19 at 12:08 pm Staff P stated they would replace the lighting fixture so nothing will effect the spray pattern of the sprinkler head.

Based on observation and interview the facility failed to ensure doors and door frame assemblies were maintained as required.

Findings:

On 03/20/19 at 12:08 pm the biohazard waste hazardous area room was observed to not have a latch plate on the door frame as required in order to keep the corridor door smoke tight and to not allow fire/smoke to spread throughout the facility.

On 03/20/19 at 12:22 pm two penetrations were observed at the top of the corridor door to room 600.

On 03/20/19 at 12:29 pm the housekeeping room corridor door next to room 600 was observed to not have a latch plate as required.

On 03/20/19 at 12:30 pm Staff P was asked why there were missing latch plates, and holes in corridor doors which need to be smoke tight. Staff P stated a procedure of inspection for corridor doors will be developed then implemented so they will be able to maintain the facility corridor doors to get them corrected.

Based on observation and interview, the facility failed to ensure facility electrical wiring and equipment was in accordance with the National Electrical Code.

Findings:

On 03/20/19 at 12:33 pm the surveyor observed there was no current inspection sticker on the Fisher Scientific Isotemp in the laboratory.

On 03/20/19 at 12:33 pm the surveyor asked staff P about the inspection for the Fisher Scientific Isotemp and he stated they will get the company vendor to complete that inspection.

On 03/20/19 at 12:58 pm the surveyor observed a hydrocollator plugged into a non-GFCI electrical receptacle.

On 03/20/19 at 12:58 pm the surveyor stated to staff P any electrical biomedical machine containing water should be plugged into a GFCI for protection as the presence of moisture greatly increases the danger of accidental shock.

On 03/20/19 at 12:58 pm Staff P stated they will get the electrical plug replaced with a GFCI and that it is an easy fix.

Based on record review and interview, the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the fire drills for 2017 and 2018 did not document transmission of a fire alarm signal.

On 03/19/19 at approximately 10:35 am the surveyor stated to Staff P the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff P stated they would add that to the fire drill documentation.

Based on record review and interview, the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the annual fire rated door assembly inspections for 2017 were not completed and the documentation did not exist.

On 03/19/18 at 12:35 pm the surveyor asked Staff P for the annual fire rated door assembly inspections. Staff P stated the annual fire rated door assembly inspection was not completed for 2017.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessments were not completed.

On 03/19/19 at 11:23 am the surveyor asked Staff P for the EES and Medical Gas building system risk assessments and Staff P stated he was not aware of the requirement. Staff P stated they will get the medical gas and EES building system risk assessments started and completed.

Based on record review and interview the facility failed to ensure medical gas system was inspected annually as required.

Findings:

Record review showed the facility had not completed a medical gas annual inspection for 2017 and 2016.

On 03/19/19 at 11:20 am the surveyor asked staff P for the 2018, 2017 and 2016 annual medical gas inspection reports. Staff P stated they only have the 2018 and had not done the 2017 or 2016.

Based on record review and interview the facility failed to ensure hospital grade electrical receptacles in patient care areas were tested after initial installation, and testing was performed at intervals defined by documented performance data as required.

Findings:

Record review showed the facility had not tested hospital grade electrical receptacles in patient care areas and the testing was not performed at designated intervals defined by their documented performance data. The electrical receptacle impedance testing documentation does not exist and the facility does not have a preventative maintenance program for the facility patient care related electrical receptacles.

On 03/19/19 at 2:45 pm Staff P was asked for patient care area electrical receptacle impedance testing/inspections. Staff P stated he was not aware of the requirement but will make sure to get it completed from this point forward.

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing was completed as required.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2016, 2017, and 2018, as the documents do not exist.

On 03/19/19 at 1:52 pm Staff P was asked to provide the annual emergency generator fuel quality testing documentation for 2016, 2017, and 2018. Staff P stated annual emergency generator fuel quality tests have no been done but they will get them done.

Based on observation and interview the facility failed to ensure extension cords were not used as a substitute for fixed wiring of a structure and are only used temporarily then removed immediately upon the completion of the purpose for which it was installed and meets the conditions of NFPA 99, 2012 Edition, 10.2.4.

Findings:

On 03/20/19 at 12:22 pm the surveyor observed an extension cord plugged into a battery charger plugged into a floor stripper in housekeeping closet room.

On 03/20/19 at 12:29 pm the surveyor observed an extension cord plugged into a refrigerator in the IT office.

On 03/20/19 at 12:29 pm the surveyor stated to staff P that extension cords are considered temporary wiring by CMS and can only be used for short periods of time not permanently as fixed wiring. Staff P stated he will take out the extension cords and work something out.