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Based on observation, interview, and review of the Hospital's Emergency Preparedness Plan, the Hospital failed to ensure a comprehensive and coordinated sheltering plan was in place for tornado warnings, as required. Specifically, the facility's emergency preparedness policy did not include detailed procedures for tornado events, lacked a clear and organized sheltering location, and did not ensure staff training or communication protocols to respond effectively in the event of a tornado warning. As a result, the facility's failure to implement appropriate sheltering measures directly affects all 45 patients, staff, and visitors across all 4 of 4 smoke zones. This lack of preparedness puts everyone within the facility at significant risk during a tornado emergency, compromising their safety and well-being during such critical situations.

Findings Include:

On June 3, 2025, during a tornado warning issued at 2:07 PM and cleared at 2:47 PM, the facility had only patient rooms identified as sheltering areas in its emergency preparedness plan. This is not consistent with the guidance that recommends more specific and secure shelter locations. The sheltering area observed was disorganized and lacked clear instructions for staff and patients. No audible announcement was made regarding the tornado warning inside the facility, despite a city tornado siren being heard at 2:16 PM. Staff did not come to check on the surveyor, indicating a breakdown in the communication process and lack of a structured response to tornado warnings. Interviews with staff on June 5, 2025, revealed that they were unaware of the facility's procedures for tornado warnings or watches. This lack of awareness violates the regulatory requirement for staff training and awareness as part of a unified emergency preparedness program. The facility's emergency preparedness plan lacked specific consideration of tornadoes, particularly regarding sheltering procedures for patients, staff, and visitors. This oversight fails to comply with §416.54 and the interpretive guidelines, which require an all-hazards approach to risk assessment and emergency planning.

The CEO and Director of Plant Operations were present and acknowledged the findings.

Based on observation, document review, and policy review, the hospital failed to meet the applicable provisions of the current LSC requirements under the National Fire Protection Association (NFPA) 101, Section 19.1.1.3.2 and NFPA 101, Section 19.1.1.1.5.

The cumulative effect of this deficient practice has the potential to place any patient, staff or visitor at the hospital at risk for serious injury, serious harm, serious impairment or death.

Findings Include:

The facility failed to ensure that the building's rehabilitation work was conducted in compliance with NFPA 101, 2012 Edition, particularly with regard to the fire safety provisions required during repair, renovation, modification, or reconstruction. Specifically, the lack of a Fire Watch and failure to properly manage water damage repairs, which involved the removal of ceiling tiles and placement of items in the corridor to collect and dry water, created significant fire hazards and jeopardized the safety of all occupants, visitors, and staff, including 14 patients who were moved to the south wing of the first floor on February 13, 2025.

During a document review and interviews on 6/5/25 it was observed:

1. Failure to Implement Fire Watch:
During the repair activities to address water leaks on the first floor (February 13, 2025, through February 18, 2025), the facility did not initiate a Fire Watch despite removing ceiling tiles in nine areas and placing items in corridors to collect and dry the water. NFPA 101, Section 19.1.1.3.2, requires fire prevention measures and adequate maintenance of safety procedures during building repairs. The lack of a Fire Watch compromised the ability to monitor and manage fire risks in these areas affecting the entire hospital emergency response of fire alarm and fire sprinkler system.

2. Inadequate Control of Sprinkler System During Rehabilitation:
The facility did not ensure that the sprinkler heads were turned to deck during the rehabilitation of the water-damaged areas. As outlined in NFPA 101, Section 19.3.5.3, health care facilities must maintain fully functional automatic sprinkler systems, which was not the case in this instance, exposing the facility to increased fire risks, especially in high-occupancy areas such as patient rooms.

3. Occupancy of Evacuated Patients in Unprotected Areas:
On February 13, 2025, 14 patients were relocated to the south wing of the first floor after being evacuated from the second floor. This relocation occurred while repairs were ongoing, and no temporary fire safety measures were implemented in the affected areas. These actions violated Section 19.1.1.1.5 and 19.1.1.3.2, which emphasize the need for a high degree of safety and fire protection for health care occupancies, especially when patients who are unable to self-preserve are involved.

4.Failure to Ensure Full Compliance During Rehabilitation Work:
The repair and renovation activities, as per NFPA 101, Section 4.6.7, must meet the requirements of Chapter 43 for rehabilitation work. However, the failure to implement fire safety protocols, such as Fire Watch and proper sprinkler system adjustments, indicated non-compliance with the safety standards necessary for health care facilities undergoing renovations.

The CEO and Director of Plant Operations were present and acknowledged the findings.

Reference:
NFPA 101, 2012 Edition, Section 4.6 (General Requirements)
NFPA 101, 2012 Edition, Section 19.1.1.1.5 (Health Care Facilities)
NFPA 101, 2012 Edition, Section 19.1.1.3.2 (Fire Prevention and Safety Procedures)
NFPA 101, 2012 Edition, Section 19.3.5.3 (Sprinkler System Requirements)
NFPA 101, 2012 Edition, Section 19.3.4.1 (Detection and Alarm Systems)
NFPA 101, 2012 Edition, Section 4.6.7 (Rehabilitation Work Compliance)