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Based on document reviews and interview, it was determined that the agency failed to maintain, review and update the Emergency Preparedness (EP) Plan every 2 years, the last review/update occurred in 2017. Failure to develop an emergency plan may cause harm to the patients and staff during an emergency and failure to ensure the EP plan was reviewed annually poses a potentail risk that all required revisions to the plan will not be recognized and revised as needed.

Based on record review and observation it was determined the facilities Alcohol Based Hand Rub Dispensers (ABHR) were not tested in accordance with the manufactures care and use instructions each time a refill is installed. ABHR dispensers not tested in accordance with the manufactures care and use instructions each time a refill is installed could cause the dispenser not to operate in an approved manner when activated.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.6 ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:

(11) Operation of the dispenser(s) shall comply with the following criteria:

(f) The dispenser shall be tested in accordance with the manufactures care and use instructions each time a refill is installed.

Findings include:

On August 25, 2020, accompanied by the Maintenance Director it was determined the facility did not have documented evidence that the facilities Alcohol Based Hand Rub Dispensers were tested in accordance with the manufactures care and use instructions each time a refill is installed. There was no policy or any other written documentation that the refills were tested in accordance with the manufactures care and use instructions shown to the surveyor while on site.

During the exit conference on August 25, 2020, the above findings were again acknowledged by the Maintenance Director.

Based on Observation it was determined the facility failed to assure that all parts of the facility were provided sprinkler system coverage. Failing to provide sprinkler coverage in all areas of the facility by blocking the sprinkler heads could result in the sprinkler not controlling the fire which could cause harm to the patients.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1,"Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater."

Findings include:

On August 25, 2020, accompanied by the Director of Maintenance it was observed in the following areas there was storage of material within the 18 inches of the sprinkler deflector when measured with a tape ruler.

1. Emergency Room Continuing Care storage room had storage within 18 inches of the sprinkler head.
2. Emergency Room Electrical Room had storage within 18 inches of the sprinkler head.

During the exit conference on August 25, 2020 the above findings were again acknowledged by the Director of Maintenance.

Based on observation it was determined that the facility failed to maintain the sprinkler heads in multiple areas in the facility. Failing to maintain sprinkler heads could cause harm to residents and staff by allowing a fire to spread before the temperature is reached to set of the sprinkler head.

NFPA 101 Life Safety Code, 2012 edition, Chapter 19, Section 19.3.5.1 "Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage."

Findings Include:

On August 25, 2020, accompanied by the Director of Maintenance, the following sprinkler heads were observed with dust/lint or paint on the sprinkler heads in the following locations:

1. 4 of 8 sprinkler heads over the main entrance had dust/lint/spider webs and wasp nest on them.
2. 1 sprinkler head in the hallway of the emergency room with dust/lint on it.
3. 3 sprinkler heads on the dining room serving line with dust/lint on them.
4. 1 sprinkler head above Bed 1 in the Sleep Lab with dust/lint on it.

During the exit conference on August 25, 2020, the above findings were again acknowledged by the Director of Maintenance and the Director of Quality.

Based on Observation it was determined that 2 rated corridor doors did not latch and close when tested three of three times. Failing to prevent the passage of heat or smoke will cause harm to the resident and staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings Include:

On August 25, 2020, accompanied by the Director of Maintenance, observed the maintenance hall corridor door and door #14 did not latch and close when tested three of three timers.

During the exit conference on August 25, 2020 the above findings were again acknowledged by the Director of Maintenance.

Based on Observation it was determined the facility did not allow access to electrical equipment panels in multiple areas in the facility. Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients could be harmed if a fire should start because of a delay.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 2011 ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

Findings include:

On August 25, 2020, accompanied by the Maintenance Director it was observed that there were blocked electrical panels in the following areas:

1. Maintenance Room electrical room had storage within 36 inches of the electrical panels.
2. In the Kitchen there was storage within 36 inches of the electrical panel (table and chair).
3. Copper Mountain Clinic had a blocked electrical panel in the storage room.
4. In the G building (storage for emergency equipment) the electrical panel was blocked by equipment.

During the exit conference on August 25, 2020, the above findings were again acknowledged by the Director of Maintenance

Based on record review and interview with the Director of Maintenance the facility failed to have an Annual fuel quality test completed for the facility diesel generator. Additionally, there was no documentation of the transfer times for restoring power to the facility. Failure to conduct a Annual fuel quality fuel test for the emergency generator and monitoring the transfer times could result in harm to patients during emergency system failures.

1. NFPA 101 Life Safety Code, 2012, Chapter 21, Section 21.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES" 2012, Chapter 6, Section 6.4.4.1.1.4 (A) Test Criteria. Generator sets shall be tested 12 times a year with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standards for Emergency and Standby Power Systems, Chapter 8. Operational Inspection and Testing. Section 8.4.1 EPPS , including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. NFPA 110 2010 Edition Standard for Emergency and Standby Power Systems; Section 8.3 Maintenance and Operational Testing Section: 8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Findings Include:

On August 25, 2020, accompanied by the Director of Maintenance reviewed the generator records weekly, monthly and most current Annual load test inspection, testing, and maintenance documentation for the emergency diesel-powered generator. The generator records for the Annual inspection inspection and testing report did not include fuel quality test was completed.

During the exit conference conducted on August 25, 2020, the above findings were again acknowledged by the Director of Maintenance.

2. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.1 "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 8, 8.4.1 * EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly, additionally Chapter 8, Section 8.4.2 "8.4.2 *
Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Findings Include:

On August 25, 2020 accompanied by the Director of Maintenance the generator test records were reviewed. No documentation of weekly or monthly transfer times within 10 seconds were documented.

During the exit conference conducted on August 25, 2020, the above findings were again acknowledged by the Director of Maintenance.

Based on Observation it was determined the facility allowed the use of a multiple outlet adapters, power strips and extension cords and did not use the wall outlet receptacles for appliances. The use of multiple outlet adapters, extension cords and power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the staff and patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On August 25, 2020 accompanied by the Director of Maintenance, observed the following power strips, extension cords and multiplug adaptors in the facility and appliances not directly plugged in to the receptacle wall outlets.

1. Extension Cords (2) in the Emergency Room copier room.
2. A refrigerator and microwave plugged into a power strip in the X-Ray department.
3. An extention cord in the CT scanner room with equipment plugged into it.
4. An extention cord in the Laboratory with test equipment plugged into it.
5. A battery back up unit (UPS) with a second UPS plugged into it.
6. A power strip with a power strip plugged into it in the Sterile Processing Department.
7. A power strip with a power strip plugged into it in the break room in building B.
8. A multiplug adapter in use in the UltraSound room (room 5) in building B.
9. A refrigerator and a space heater plugged into a UPS in the office in the Copper Mountain Clinic.
10. A power strip plugged into a UPS in an office in the Copper Mountain Clinic.

During the exit conference on August 25, 2020 the above findings were again acknowledged by the Director of Maintenance.

Based on Observation the facility failed to secure three medical gas E-type oxygen medical gas oxygen cylinders in a stand or cart. Failing to secure compressed medical gas cylinders could cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

On August 25, 2020, accompanied by the Director of Maintenance three unsecured medical gas oxygen cylinders E-type were observed not secured. Two were located in the temporary ICU and one was located in the medical/surgical storage room, none were not secured in a rack or stand.

During the exit conference on August 25, 2020, the above findings were again acknowledged by the Director of Maintenance.

Based on interview with the Administrator and Director of Maintenance it was determined the facility failed to provide programs for continuing education and periodic review of safety guidelines and usage requirements for medical gases and oxygen cylinders. Failing to provide programs and periodic review of safety guidelines of oxygen cylinders or liquid oxygen could cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.5.2.1" Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.

Findings include:

On August 25, 2020, accompanied by the Director of Maintenance and the Director of Quality were interviewed and asked about the facilities programs for continuing education programs and periodic review of safety guidelines and usage requirements for medical gases and oxygen cylinders. No documentation was provided to the surveyor to review while on site.

During the exit conference on August 25, 2020 the above findings were again acknowledged by the Director of Maintenance and the Director of Quality.

Based on record review and interview with staff, it was determined the facility failed to have a documented Wet Procedure Risk Assessment. Failure to establish procedures for operating rooms emergencies and periodic evaluations made of hazards that could be encountered during surgical procedures could lead to patient injury or death.

NFPA 99 2012 Edition, Section 15.13 Fire Loss Prevention in Operating Rooms. 15.13.1 Hazard Assessment. 15.13.1.1 An evaluation shall be made of hazards that could be encountered during surgical procedures. 15.13.1.2 The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. 15.13.1.3 Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel.

Findings include:

On August 25, 2020, accompanied by the Director Maintenance and the Director of Quality reviewed the facility's policies. No documentation was reviewed providing a Wet Procedure Risk Assessment for the Operating Room.

During the exit conference conducted on August 25, 2020, the above findings were acknowledged by the Director of Quality and the Director of Maintenance.