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Based on Life Safety Code (LSC) survey, Scott Memorial Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 485.623(d)(1), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18, New Health Care Occupancies for the 2007 surgery addition and Chapter 19, Existing Health Care Occupancies for the original building.

The facility was constructed at two different times. The original building is a one story, sprinkled building of Type II (222) construction. In 2007, a one story addition to the southwest of the original building was constructed and is a one story, sprinkled addition of Type II (222) construction. The original building was surveyed with NFPA 101, LSC, Chapter 19, Existing Health Care Occupancies and the 2007 surgery addition was surveyed with NFPA 101, LSC Chapter 18, New Health Care Occupancies. The facility has a fire alarm system with smoke detection in the corridors, spaces open to the corridors, and hard wired smoke detection in all patient sleeping rooms. The facility has a capacity of 25 and had a census of 3 at the time of this survey.

Based on LSC survey and deficiencies found (see 2567L), it was determined that the facility failed to ensure penetrations through 5 of 12 smoke barriers in the original building and 3 of 5 smoke barriers in the 2007 surgery addition were protected to maintain the smoke resistance of the smoke barrier (see K 025), failed to conduct quarterly fire drills on each shift for 3 of 4 quarters over the past year (see K 050), failed to ensure 1 of 68 smoke detectors in the original building and 1 of 24 smoke detectors in the 2007 surgery addition were not located where airflow would prevent the operation of the detector (see K 052), failed to ensure 1 of 1 Post Indicator Valve (PIV) was provided with an electrical alarm which alarmed when the valve was closed (see K 061), failed to ensure 1 of 1 automatic dry sprinkler piping systems was inspected every five years in the 2007 surgery addition, failed to provide a complete supply of spare sprinklers for the automatic sprinkler system for the Med 2 West Hall and failed to ensure 1 of 1 private fire hydrant near the helicopter pad was continuously maintained in reliable operating condition and inspected and tested periodically (see K 062) and failed to ensure 2 of 3 emergency generators with over 100 horsepower in the original building were equipped with a remote manual stop (see K 144).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, observation, and interview, the hospital failed to ensure preventive maintenance for 8 pieces of equipment (hand bike, crutches, quad cane, walker, parallel bars, wooden stair set, floor scrubber, and patient beds)

Findings:

1. Review of the policy & procedure (P&P) titled Preventative Maintenance(PM) indicated the purpose was to ensure equipment at the hospital is properly maintained and managed and procedure to include PM scheduled according to manufacturer's recommendations, area served by the equipment, condition of the equipment and experience of the maintenance department. The P&P was effective 12/17/14.

2. On 5/18/15 at 12:00 pm during facility tour, in the presence of A1, Chief Executive Officer A12, Medical Laboratory Technologist, & S8, Maintenance Supervisor, the following was observed in the activities room: a hand bike, crutches, a walker, a quad cane, parallel bars, & wooden exercise stairs.

3. Review of facility PM documents lacked evidence of PM for the following activities room equipment: hand bike, crutches, walker, quad cane, parallel bars, & wooden exercise stairs and lacked evidence of PM for the floor scrubber and patient beds.

4. On 5/20/15 at 12:20 pm, A4, Director of Building Services, confirmed the above equipment did not have regular PM.

Based on observation, record review and staff interview, the facility failed to ensure penetrations through 5 of 12 smoke barriers in the original building and 3 of 5 smoke barriers in the 2007 surgery addition were protected to maintain the smoke resistance of the smoke barrier, failed to conduct quarterly fire drills on each shift for 3 of 4 quarters over the past year, failed to ensure 1 of 68 smoke detectors in the original building and 1 of 24 smoke detectors in the 2007 surgery addition were not located where airflow would prevent the operation of the detector, failed to ensure 1 of 1 Post Indicator Valve (PIV) was provided with an electrical alarm which alarmed when the valve was closed, failed to ensure 1 of 1 automatic dry sprinkler piping systems was inspected every five years in the 2007 surgery addition, failed to provide a complete supply of spare sprinklers for the automatic sprinkler system for the Med 2 West Hall and failed to ensure 1 of 1 private fire hydrant near the helicopter pad was continuously maintained in reliable operating condition and inspected and tested periodically and failed to ensure 2 of 3 emergency generators with over 100 horsepower in the original building were equipped with a remote manual stop.

Findings:

1. In observations with BSD1, the building service director on 05/19/15 from 1:20 p.m. to 2:00 p.m., it was noted the following smoke barrier walls above the drop ceiling had penetrations not fire stopped or missing drywall:
a. The Laboratory Hall smoke barrier wall had a cable bundle penetration with a one inch gap around the cable bundle not fire stopped.
b. The X-ray Hall south smoke barrier wall had a four inch electrical conduit penetration which was open and not fire stopped.
c. The X-ray Hall west smoke barrier wall had a four inch by six inch opening with no drywall on the south side of the wall and four electrical conduit penetrations with one half inch gaps not fire stopped.
d. The Med 3 Hall north smoke barrier wall had a one inch gap around an electrical conduit penetration and a one half inch gap around a cable bundle not fire stopped.
e. The Unit 3 Hall south smoke barrier wall had a one inch circular area of drywall missing next to an electrical conduit penetration.

2. The smoke barrier penetrations not fire stopped and missing drywall was verified by BSD1 at the time of observations and acknowledged by the CEO, chief executive officer at the exit conference on 05/19/15 at 2:15 p.m.
3. In observations with BSD1 on 05/19/15 from 1:20 p.m. to 2:00 p.m., it was noted the following smoke barrier walls above the drop ceiling had penetrations not fire stopped or missing drywall:
a. The Surgery entrance Hall west smoke barrier wall had an eight inch by eight inch square area of drywall missing and a three inch circular area of drywall missing.
b. The Surgery Hall north smoke barrier wall had three, two inch circular areas of drywall missing, and two, one half inch gaps around metal duct penetrations not fire stopped.
c. The Surgery Hall east smoke barrier wall had sixteen electrical conduit penetrations with one half inch gaps not fire stopped, a three inch circular area of drywall missing, and a four inch open conduit with no fire stopping material.

4. The smoke barrier penetrations not fire stopped and missing drywall was verified by BSD1 at the time of observations and acknowledged by the CEO at the exit conference on 05/19/15 at 2:15 p.m.

5. Review of Fire Drill & Alarm Reports with BSD1 on 05/19/15 at 9:15 a.m. indicated there were no records of a fire drill for the fourth quarter of the year 2014 on third shift, the third quarter of the year 2014 on second shift and the second quarter of the year 2014 on third shift.

6. Interview with BSD1 on 05/19/15 at 9:30 a.m. confirmed there was no other documentation available for review to verify the missed fire drills were conducted.

7. The above was acknowledged by the CEO at the exit conference on 05/19/15 at 2:15 p.m.

8. It was observed on 05/19/15 at 12:10 p.m. with BSD1 that the Med 2 Hall had a smoke detector located one foot from a heating and air conditioning ceiling mounted unit.
9. This was verified by BSD1 at the time of observation and acknowledged by the chief executive office at the exit conference on 05/19/15 at 2:15 p.m.
10. On 05/19/15 at 11:05 a.m. with BSD1, it was observed that the 2007 surgery addition mechanical had a smoke detector located one foot from a supply air duct.

11. This was verified by BSD1 at the time of observation and acknowledged by the CEO at the exit conference on 05/19/15 at 2:15 p.m.

12. Observation on 05/19/15 at 10:40 a.m. with BSD1 noted the post indicator valve, located in the staff parking lot, was not provided with an electrical connection on the valve. Furthermore, the fire alarm system main panel did not list the post indicator valve on the panel's label.
13. The lack of an electrical alarm on the post indicator valve was verified by BSD1 at the time of observation and acknowledged by the CEO at the exit conference on 05/19/15 at 2:15 p.m.
14. Record review with BSD1 on 05/19/15 at 9:45 a.m. evidenced there was no documentation to indicate an internal inspection of the dry sprinkler system had been conducted in the past five years.

15. Observation of the dry sprinkler riser on 05/19/15 at 11:45 a.m. with BSD1 indicated the dry sprinkler riser, located in the main mechanical room, had a date of the last internal pipe inspection dated July 2006.

16. The lack of a five year internal pipe inspection was verified by BSD1 at the time of record review and acknowledged by the CEO at the exit conference on 05/19/15 at 2:15 p.m.

17. Observations on 05/19/15 during the tour of the Med 2 West Hall with BSD1 from 12:20 p.m. to 1:00 p.m. noted the fourteen rooms on the Med 2 West Hall each had sidewall sprinklers.

18. Observation of the spare sprinkler cabinets in the maintenance office sprinkler riser room and the main mechanical sprinkler riser room noted the two spare sprinkler cabinets lacked sidewall sprinklers.

19. The lack of spare sidewall sprinklers was verified by BSD1 at the time of observation and acknowledged by the CEO at the exit conference on 05/19/15 at 2:15 p.m.

20. Observation on 05/19/15 at 1:15 p.m. with BSD1 indicated the facility had one private fire hydrant near the helicopter pad.

21. In interview with BSD1 on 05/19/15 at 1:25 p.m., it was indicated there is no documentation of an annual inspection for the fire hydrant.

22. The lack of an annual inspection for the one fire hydrant near the helicopter pad was acknowledged by the CEO at the exit conference on 05/19/15 at 2:15 p.m.

23. Observation of the emergency generator set outside enclosures on 05/19/15 at 1:10 p.m. with BSD1 noted the two emergency generator sets for the original building were not provided with a manual stop switch at a remote location.

24. This was verified by BSD1 at the time of observation and acknowledged by the CEO at the exit conference on 05/19/15 at 2:15 p.m.

Based on policy and procedure review, document review, and staff interview, the facility failed to administer blood transfusions in accordance with approved medical staff policies and procedures for 1 of 1 (patient #19) open patient medical record reviewed and 5 of 11 (patients #20-24) closed patient medical records reviewed.

Findings:

1. Policy #NUR 11.0011, Blood and Blood Product Administration, revised/reapproved 2/2014, indicated on pg:
A. 3, under Patient Information section, point 1., "At a minimum, the patient's temperature, pulse and blood pressure are taken and recorded prior to, 15 minutes after initiating, and at the completion of a transfusion."
B. 4, under Procedure section, point 6., "Evaluate pre-transfusion vital signs before obtaining blood to make sure transfusion can be performed (e.g. an elevated temperature may delay transfusion)..."
C. 6, under Procedure section, point 20., "At the time of the 60 minute vital signs, evaluate transfusion progress for timeliness..."

2. Review of open and closed patient medical records on 5/19/15 and 5/20/15 at approximately 1000 hours and 1027 hours, confirmed:
A. patient #19:
a. received a transfusion of packed red blood cells (PRBCs) on 5/19/15 that was started at 0205 hours.
b. the last recorded pre-transfusion vital signs were at 0205, which is not prior to the start of the transfusion.

B. patient #20:
a. received a transfusion of PRBCs on 5/6/15 that was started at 1438 hours.
b. the last recorded pre-transfusion vital signs were at 1438, which is not prior to the start of the transfusion.
c. the transfusion was stopped at 1654 and the 60 minute vital sign was recorded as 1700, which is 6 minutes after the transfusion was stopped.
d. received another transfusion of PRBCs on 5/13/15 that was started at 1123 hours.
e. the last recorded pre-transfusion vital signs were at 1123, which is not prior to the start of the transfusion.
f. the transfusion was stopped at 1352 and the 60 minute vital sign was recorded as 1425, which is 33 minutes after the transfusion was stopped.

C. patient #21:
a. received a transfusion of packed red blood cells (PRBCs) on 5/11/15 that was started at 1952 hours.
b. the last recorded pre-transfusion vital signs were at 1952, which is not prior to the start of the transfusion.

D. patient #22:
a. received a transfusion of packed red blood cells (PRBCs) on 4/30/15 that was started at 2008 hours.
b. the last recorded pre-transfusion vital signs were at 2008, which is not prior to the start of the transfusion.

E. patient #23:
a. received a transfusion of packed red blood cells (PRBCs) on 4/29/15 that was started at 1542 hours.
b. the last recorded pre-transfusion vital signs were at 1542, which is not prior to the start of the transfusion.
c. the transfusion was stopped at 1922 and the 60 minute vital sign was recorded as 1925, which is 3 minutes after the transfusion was stopped.

F. patient #24:
a. received a transfusion of packed red blood cells (PRBCs) on 4/28/15 that was started at 0131 hours.
b. the last recorded pre-transfusion vital signs were at 0131, which is not prior to the start of the transfusion.

3. Staff #26 (Lab Director) was interviewed on 5/19/15 at 3:14 PM, and confirmed the above-mentioned patients lacked pre-transfusion vital signs and/or 60 minute post-transfusion vital signs as required by facility policy and procedure.

Based on document review, observation, and interview, the facility failed to ensure unauthorized access to patient records for 4 cardboard boxes of medical records (MR) in one location (maintenance shop).

Findings:

1. Review of the policy & procedure (P&P) titled Secure Medical Record Storage indicated 1. Medical records must be properly filed and stored in a secure location(s) that safeguard from the following: b. Man made hazards such as theft, accidental loss, sabotage, etc. d. Unauthorized use, disclosure, and destruction. 2. Secure location means the location must ensure the integrity, security and protection of the records and are limited to access only by authorized individuals. The P&P was approved 9/2013.

2. On 5/18/15 between 11:00 am and 12:00 pm during facility tour, in a storage aisle of the maintenance shop, in the presence of A1, Chief Executive Officer (CEO) and S8 (maintenance supervisor), 4 cardboard boxes were on shelves and labeled as follows: Path reports, path and lab, blood bank, & lab. Inside the boxes were multiple patients' medical records documentation.

3. On 5/18/15 at 12:00 pm, A1 and S8 indicated maintenance personnel did not have authorized access to MRs and the records should not be in that location.

Based on document review and interview, the quality assessment and improvement program (QAPI) failed to evaluate all areas by not including 4 of 28 directly provided services (infusion therapy, pediatrics, pharmacy,& inpatient rehabilitation), 2 of 12 functions (transcription & utilization review), and 3 of 6 contracted services (biomedical engineering, laundry, & teleradiology).

Findings:

1. Review of 1/2014 to 12/2014 & 1/2015 to 4/2015 QAPI meeting minutes lacked evidence of quality assurance evaluation for the directly provided services of infusion therapy, pediatrics, pharmacy,& inpatient rehabilitation, the functions of transcription & utilization review, and the contracted services of biomedical engineering, laundry, & teleradiology.

2. On 5/20/15 at 12:45 pm, A3, Director of Quality Risk Management, confirmed the above were not included in the QAPI program reports.