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Based on record review and interview, the facility failed to ensure emergency preparedness program (EPP) include at a minimum, (1) The provision of subsistence needs for staff and residents, whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical, and pharmaceutical supplies. (ii) Alternate sources of energy to maintain - (A) Temperatures to protect resident health and safety and for the safe and sanitary storage of provisions; (B) Emergency lighting; (C) Fire detection, extinguishing, and alarm systems; and (D) Sewage and waste disposal in accordance with 42 CFR 485.625 This deficient practice could affect all occupants.

Findings include:

Based on records review with the Director of Facilities on 07/01/19 at 3:15 p.m., the subsistence needs documentation for the EPP was incomplete. Documentation for temperatures to protect patient health and safety was not available for review. Based on interview at the time of record review, the Director of Facilities agree that a complete policy on extreme Temperature was not in the EPP.

Based on record review and interview, the facility failed to ensure Emergency Preparedness Plan (EPP) include a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records in accordance with 42 CFR 485.625(b)(4). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Director of Facilities on 07/01/19 at 3:25 p.m., the provided EPP did not include documentation to indicate the use of a system to preserve patient medical documentation during an emergency. Based on interview at the time of record review then again at the exit conference, the Director of Facilities was unable to find a policy on a system to preserve patient medical documentation in the EPP.

Based on record review and interview, the facility failed to maintain complete documentation of training for the Emergency Preparedness Program (EPP). The Hospital or RHC/FQHC must do all of the following::(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles; (ii) Provide emergency preparedness training at least annually; (iii) Maintain documentation of the training; (iv) Demonstrate staff knowledge of emergency procedures in accordance with 42 CFR 485.625(d) (1). This deficient practice could affect all patients in the facility.

Findings include:

Based on records review with the Director of Facilities on 07/01/19 at 4:05 p.m., there was no documentation available for review to show staff was trained annually on the EPP. Based on an interview at the time of records review, the Director of Facilities stated staff have been trained but it was not documented.

Based on observation and interview, the facility failed to ensure 1 of 1 third floor soiled utility corridor doors to a hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2. This deficient practice could affect 10 patients on the third floor.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 11:53 a.m., the third floor soiled utility room contained dirty linen and trash with a self-closing device on the door, but when fully opened the door was held open with a locking feature on the self-closing device that did not release with the fire alarm. Based on interview at the time of observation, the Director of Facilities agreed there was a locking feature on the self-closer that held the door open and did not release with activation of the fire alarm.

Based on observation and interview, the facility failed to ensure the lighting for 2 of 12 exit means of egress were arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. LSC 7.8.1.4 requires illumination shall be arranged so that that the failure of any single lighting unit does not result in an illumination level of less than 0.2 foot-candle in any designated area. This deficient practice could affect staff and visitors in the facility.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 1:10 p.m. and at 2:37 p.m., the exit discharge outside the generator exit included one egress light with only one bulb and outside the physicians exit no egress light was installed. Based on interview at the time of observations, the Director of Facilities confirmed the generator exit light only included one bulb and the physicians exit did not include a light.

Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 1 rooms with combustible storage and greater than 50 square feet, and 1 of 1 soiled utility room were provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect visitors on the first floor and 5 patients on the fifth floor.

Findings include:

1) Based on observation with the Director of Facilities on 07/02/19 at 10:17 a.m., the first floor accounting storage room contained over 50 boxes of paper records, was greater than 50 square feet, and did not have a self-closing door. Based on interview at the time of observation, the Director of Facilities agreed a room was used as storage for boxes, was larger than 50 square feet, and the door to the room was not self-closing. The Director of Facilities did state the boxes were going to be shipped and removed from the office.
2) Based on observation with the Director of Facilities on 07/02/19 at 11:00 a.m., the fifth floor soiled utility room which contained three large barrels of trash and soiled linen did not contain a self-closing door. Based on interview at the time of observation, the Director of Facilities stated staff relocated the soiled utility room to a room that did not contain a self-closing door.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect staff, visitors, and up to 10 patients on the second floor.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 2:20 p.m. and at 3:31 p.m., in the gift shop storage room and in the Ambulance entrance there were vents about 12 inches from a smoke detector. Based on interview at the time of observation, the Director of Facilities acknowledged the smoke detectors were located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening.

1. Based on observation and interview, the facility failed to ensure that a complete automatic sprinkler system were provided for 1 of 1 storage closets and 1 of 1 telephone rooms. LSC 19.3.5.3 states where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. This deficient practice could affect visitors, staff, and patients using the first floor entrance.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 10:15 a.m. and at 10:45 a.m., the first floor Accounting storage closet was not provided with sprinkler coverage. Also, the first floor Telephone room was not provided with sprinkler coverage. Based on interview at the time of observation, the Director of Facilities agreed there was no sprinkler coverage for the closet and telephone room and stated sprinkler coverage will need to be added to the rooms.

2. Based on observation and interview, the facility failed to ensure 1 of 4 automatic sprinkler system was installed in accordance with NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13, Section 8.6.3.4, "Minimum Distance between Sprinklers", states sprinklers shall be spaced not less than 6 feet on center. In addition, LSC 4.6.7.5 requires existing life safety features that do not meet the requirements for new buildings, but exceed the requirements for existing buildings shall not be further diminished. This deficient practice could affect visitors, staff, and patients using the first floor entrance.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 10:10 a.m., the following first floor areas contained sprinkler heads about 3 feet apart.
a) In the back half of the Accounting office.
b) In the back half of the Accounting storage room.
c) In the front half of the Accounting storage room.
c) In the hall right outside of the Accounting storage room.
Based on interview at the time of the observations, the Director of Facilities acknowledged the distance of the aforementioned sprinkler heads sets as being less than 6 feet in distance apart from each other.

Based on observation and interview, the facility failed to ensure monitoring of 1 of 1 post indicator valves (PIV). LSC 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 10:10 a.m., there was a PIV outside the sprinkler riser/chiller room. The PIV was locked in the open position but did not have any electronic supervision. Based on interview at the time of observation, Director of Facilities agree the PIV was not electrically supervised.

Based on observation and interview, the facility failed to ensure 3 of 3 sprinkler system gauges on the MRI riser were replaced every 5 years or documented as tested every 5 years by comparison with a calibrated gauge. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.3.2.1 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect 2 patients, staff, and visitors in the MRI area.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 2:58 p.m., on the second floor in the imaging center the MRI Riser contained three gauges that had a date of 2012. No recalibration date information was affixed to the sprinkler system gauge. Based on interview at the time of the observation, the Director of Facilities stated the gauges were more than five years old and needed replaced.

Based on observation and interview, the facility failed to ensure 3 of 3 flexible cords power strips in patient care locations met the required UL rating of 1363A or 60601-1. This deficient practice did affect one patient in exam room 323 and one patient in Operating Room (OR) 2.

Findings include:

1. Based on observation with the Director of Facilities on 07/02/19 at 11:44 a.m., in room exam 323 there was one power strip plugged into another power strip next to patient exam table that did not met UL 1363A or 60601-1. Based on interview at the time of observation, the Director of Facilities agreed two power strips were in use next to a patient exam table and did not meet 1363A or 60601-1.
2. Based on observation with the Director of Facilities on 07/02/19 at 2:40 p.m., in OR 2 there was a multi-plug power box attached to an IV pole powering medical equipment containing markings identifying it as medical grade but the list UL number on the power box was UL E247329. Based on interview at the time of observation, the Director of Facilities agreed the power box was in a patient care area and did not meet 1363A or 60601-1.