HospitalInspections.org
Bringing transparency to federal inspections
HARPER COUNTY COMMUNITY HOSPITAL
Egress Doors
Tag No.: K0222
Based on observation and interview the facility failed to ensure opening doors to access to the emergency egress pathway would only take one action to open as required.
Findings:
On 05/11/21 at 9:54am the surveyor observed one deadbolt lock on each of the procedure room doors in the surgery area which would require two actions to open to gain access to the emergency egress pathway.
On 05/11/21 at 9:54am the surveyor asked staff A why they had deadbolt locks on each of the procedure doors. Staff A stated they were wanting to control traffic but can install the correct locks which are compliant to code.
Illumination of Means of Egress
Tag No.: K0281
Based on observation and interview the facility failed to ensure each emergency exit discharge area was provided with emergency powered lighting.
Findings:
On 05/11/21 at 12:04 pm the surveyor observed each of the facility's four emergency exit discharges did not have battery backed up emergency powered lighting or generator wired emergency powered lighting.
On 05/11/21 at 12:04 pm the surveyor asked staff A why the facility did not have exit discharge emergency lighting. Staff A stated it has been that way as long as they can remember but they will install emergency powered battery backed up lighting at each of the four exit discharges or have emergency exit discharge lighting wired to the emergency generator at each of the four exits of the facility in order to meet compliance.
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and interview the facility failed to ensure hazardous areas are properly protected from other use spaces.
Findings:
On 05/11/21 at 12:44 pm the surveyor observed three penerations in the medical records storage smoke barrier.
On 05/11/21 at 12:44 pm the surveyor asked staff A stated why there were penetrations in the smoke barrier protecting the medical records hazardous area. Staff A stated they did not know why but will get the penetrations corrected to be in compliance.
Gas and Vacuum Piped Systems - Inspection and
Tag No.: K0908
Based on record review and interview the facility failed to ensure the medical gas system was inspected and maintained as required.
Findings:
Record review showed the facility did not complete an annual medial gas inspection for 2018 and 2019.
On 05/10/21 at 11:45am the survyeor asked staff A why there was no annual medical gas inspection for 2018 and 2019. Staff A stated they it must have been overlooked but will be corrected to be in compliance.
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on record review and interview the facility failed to ensure the emergency generator fuel testing was completed as required.
Findings:
Record review showed generator fuel testing was not completed for 2020, 2019 and 2018.
On 05/10/21 at 1:52pm Staff A was asked to provide the emergency generator fuel testing for 2020, 2019 and 2018. Documentation for generator fuel testing was not provided for those three years.
On 05/10/21 at 1:54pm the surveyor asked staff A why generator fuel testing was not done for 2020, 2019 and 2018. Staff A stated they will get the emergency generator fuel testing initiated for their generator program.
Gas Equipment - Cylinder and Container Storag
Tag No.: K0923
Based on observation and interview the facility failed to ensure oxygen cylinders were properly stored as required.
Findings:
On 05/11/21 at 12:22pm the surveyor observed 16 full E sized oxygen cylinders unsecured and sitting on the ground.
On 05/11/21 at 12:23pm the surveyor asked staff A why the oxygen cylinders were unsecured and sitting directly on the ground. Staff A stated that the vendor must have left them there but will get someone to properly secure them.