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Based on record review and interview, the hospital failed to ensure development, maintenance, and annual review of a facility-based community-based risk assessment using an all hazards approach as required.

Findings:

Record review of the emergency preparedness plan showed the facility did not annually maintain and review the facility-based and community-based risk assessments that utilized an all hazards approach. An annual risk assessment for the facility emergency preparedness plan did not exist for 2017-2018.

On 07/08/19 at 11:17 am, the surveyor asked Staff A for written documentation of the facility's risk assessments and associated emergency preparedness strategies. Staff A stated the risk assessment had not been updated annually since 2012.

Based on record review and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed the role of the facility under the 1135 waiver declared by the president in accordance with section 1135 of the act in provision of care and treatment. The facility lacked a policy.

Findings:

Record review of the facility's Emergency Preparedness plan showed that they lacked a policy regarding the facility's roles under a 1135 waiver during a declared disaster.


On 07/08/19 at 10:50 am, the surveyor asked Staff A if the facility established policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff A stated the facility is in process of updating policies to ensure compliance. The document did not exist.

Record review and interview of the facility emergency preparedness communication plan did not contain methods for sharing information and medical documentation for patients under the facility's care with other health care providers to maintain continuity of care in the event of an evacuation as required.

Findings:

Record review and interview showed the facility communication plan developed did not contain methods for sharing
information with other health care providers during evacuation.

On 07/08/19 at 4:33 pm, the surveyor asked Staff B for documentation to verify the facility had developed an emergency preparedness communication plan which included how the facility would share information for patients under the facility's care as necessary with other health care providers in the event of an emergency. Staff B stated the facility would update and revise communication plan to address sharing information in the event of an evacuation as permitted under 45 CFR 164.510(b)(4). The document did not exist.

Based on interviews and document review the facility failed to participate in a full scale, individual, or facility tabletop exercise resulting in the lack of data being analyzed so the facility's emergency plan could be evaluated and updated if required.

Findings:


Record review and interview showed the facility failed to ensure an emergency preparedness drill had occurred either by full scale community activity, individual or facility based.

On 07/08/19 at 4:50 pm, surveyor asked Staff B for documentation the facility participated in a community based exercise. Staff B reported the facility had not completed a community based drill for 2018.

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 2018 were not completed and the documentation did not exist.

On 07/08/19 at 2:33 pm the surveyor asked Staff L for the annual fire rated door assembly inspections. Staff L stated the inspection was not completed for 2018 and the documentation does not exist.

Based on observation and interview the facility failed to ensure egress doors could be opened with one action and a set of egress doors swung in the direction of egress as required.

Findings:

On 07/08/19 at 3:12 pm the surveyor observed a set of glass swinging exit enclosure egress doors to the right of the main entrance in which the doors swing the opposite way of the emergency egress pathway.

On 07/08/19 at 4:17 pm the surveyor observed one deadbolt lock on the radiology corridor door and a barrel latch on the laboratory corridor door which is prohibited by CMS.

On 07/08/19 at 4:17 pm the surveyor asked staff L why there were deadbolts on the corridor doors which would take two actions to open. Staff L stated the deadbolts were on the doors within the facility since he has started and he did not know they were not allowed. Staff L stated they would have them changed with a lock that will only take one action to open the door to be in compliance.

Based on observation and interview the facility failed to ensure no items were stored within the stairway exit enclosure as required.

Findings:

On 07/08/19 at 4:08 pm the surveyor observed a metal locker, artifical Christmas tree, boxes of cieling tiles, medical film station, stored within the stairwell exit enclosure which also decreased the clear width to less than four feet.

On 07/08/19 at 4:08 pm the surveyor asked staff L why the items were stored in a restricted area. Staff L stated he was not familair with the requirement of not storing items within the stairwell but will relocate the items.

Based on record review and interview the facility failed to ensure monthly and yearly testing of emergency lighting as required.

Findings:

Record review showed the facility was not completing doing weekly checks of emergency battery backed up emergency lighting monthly and yearly.

On 07/08/19 at 2:13 pm the surveyor asked staff L for all required documentation including a partial list of documents which included paperwork to verify monthly and yearly testing of battery backed up emergency lighting throughout the facility at the entrance conference at 10:00 am and the documentation was not provide over the four hour timeframe.


7.9 Emergency Lighting.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in
accordance with one of the three options offered by 7.9.3.1.1,
7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 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).
(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 11.2 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.

Based on observation and interview the facility failed to ensure hazardous areas were free from penetrations.

Findings:

On 07/08/19 at 4:06 pm the surveyor observed multiple penetrations in the mechanical closet next to the maintenance office with the door to the mechanical closet wired open.

On 07/08/19 at 4:06 pm the surveyor asked staff L why the penetrations were in the mechanical closet and the door wired open which would allow smoke and fire to spread throughout the facility in the event of a fire. Staff L stated they will not wire the door open any longer and will fill the penetrations in the mechanical closet in addition to inspecting each of the other hazardous areas to fill potential penetrations they may find.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 07/08/19 at 5:40 pm one ABC class fire extinguisher was observed in the kitchen with no placard posted next to it to indicate the hood fire protection system shall be activated prior to using the fire extinguisher as required.

On 07/08/19 at 5:40 pm Staff L stated he would get with their fire service vendor to get the appropriate placard for the fire extinguisher.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on record review, observation and interview the facility failed to ensure portable fire extinguishers were inspected monthly as required per NFPA 10.

Findings:

Record review showed portable fire extinguishers installed throughout the facility were not being inspected on a monthly basis as the green monthly check tags were blank on each one inspected.

On 07/08/19 at 3:56 pm the surveyor asked staff L why the green monthly check tags on the portable fire extinguishers are blank. Staff L stated they did not know they were to be filled out but will take care of it from this point on.

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 facility fire drills for 2018 and 2017 did not document a transmission of a fire alarm signal for every fire drill completed.

On 07/08/19 at 3:54 pm the surveyor stated to Staff L the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff L stated they would add that to the fire drill documentation.

Based on observation and interview the facility failed to ensure trash collection receptacles with capacities greater than 32 gallons shal not be store open to the egress corridor and stored in a room protected as a hazardous area when not atttended as required.

Findings:

On 07/08/19 at 5:45 pm the surveyor observed a plastic contained over 32 gallons with biohazard waste stored open to the egress corridor in the Emergency Room.

On 07/08/19 at 5:45 pm the surveyor asked staff L why the over 32 gallon container of biohazard waste was stored open to the egress corridor in the ER. Staff L stated the ER staff need it for the waste but they will relocate it in a proper area.

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 2018 were not completed and the documentation did not exist.

On 07/08/19 at 2:33 pm the surveyor asked Staff L for the annual fire rated door assembly inspections. Staff L stated the inspection was not completed for 2018 and the documentation does not exist.

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 assessment were not completed. They do not exist.

On 07/08/19 at 2:35 pm the surveyor asked staff L for the EES and Medical Gas building system risk assessments, and staff L stated he would check. Staff L came back a time later and stated they do not have the EES and medical gas building system risk assessments. Staff L stated they will get them completed.

Based on record review and interview the facility failed to ensure impedance testing/maintenance to hospital grade electrical receptacles in patient care areas were placed on a preventative maintenance program based on intervals defined by documented performance data as required.

Findings:

Record review showed the facility did not complete impedance testing for patient care related electrical receptacles as required.

On 07/08/19 at 11:27 am the surveyor asked staff L why the impedance testing has not been completed. Staff L stated he was not totally familiar with all of the requirements for life safety code since he just recently started in his position but will get the testing scheduled to be done with their electrical contractor.

Based on record review and interview the facility failed to ensure emergnecy generator annual fuel testing, and preventative maintanence where completed as required.

Findings:

Record review showed no preventative maintenance records for the emergency generator and no annual fuel testing.

On 07/08/19 at 11:15 am the surveyor asked staff L for the emergency generator annual fuel testing for 207, 2018 and 2019 along with the preventative maintenance records. Staff L stated there has not been any preventative maintenance on the emergency generator since 1975 and the belts and hoses need replacing. Staff L stated they have not done fuel testing but will.

Based on observation and interview the facility failed to ensure electrical equipment was protected as required.

Findings:

On 07/08/19 at 4:46 pm the surveyor observed a white residential extension cord daisy chained into a power tap at the nurses station on the second floor and a hydrocollator plugged into a non-GFCI electrical receptacle sitting on top of a combustible plastic sagging cart.

On 07/08/19 at 4:46 pm the surveyor asked staff L why a extension cord is daisy chained into a power tap and the hydrocollator is plugged into a non-GFCI eletrical receptacle. Staff L stated they will remove the extension cord and install a GFCI plug to correct the issues. Staff L stated the staff are trained to know not to use extension cords.

Based on record review and interview the facility failed to ensure facilty medical gas systems were maintained and annual medical gas testing was completed as required.

Findings:

Record review showed an annual medical gas inspection dated 08/30/17 by Simplex Grinnell with multiple deficiencies found in the report. The facility did not complete annual medical gas inspections for 2018 and 2019.

On 07/08/19 at 2:12 pm the surveyor asked staff L for the documentation indicating all the impairments outlined in the 08/30/17 Simplex Grinnell medical gas system inspection report were repaired/replaced, and the 2018/2019 annual medical gas inspections. Staff L stated they do not have them as they do not exist.

Based on observation and interview the facility failed to ensure oxygen cylinders were properly secured as required.

Findings:

On 07/08/19 at 5:20 pm the surveyor observed ten "E" cylinders, and four "H" cylinders were not properly secured.

On 07/08/19 at 5:20 pm the surveyor asked staff L why the oxygen cylinders were not secured. Staff L stated their vendor did not secure them and they did not find it.

Based on observation and interview the facility failed to ensure liquid oxygen cylinders were properly secured as required.

Findings:

On 07/08/19 at 5:20 pm the surveyor observed six liquid oxygen cylinders not secured. Four of the liquid oxygen tanks were connected to the oxygen manifold and two were standing next to the gate and each were not properly secured.

On 07/08/19 at 5:20 pm the surveyor asked staff L why the liquid oxygen cylinders were not secured. Staff L stated their vendor did not secure them and they did not find it.