HospitalInspections.org

Based on record review and interview, it was determined the facility failed to conduct a comprehensive facility-based and community-based risk assessment to include strategies for addressing emergency events identified by the risk assessment. Failure to conduct a facility and community-based risk assessment with strategies for response hinders the facility's ability to respond to localized disasters and emergencies. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings include:

On April 16, 2019, from approximately 8:00 AM to 2:30 PM, review of the provided emergency preparedness plan, including the facility Hazard Vulnerability Assessment (HVA) revealed some of the hazards identified on the HVA did not have strategies for response, and some of the strategies for response in the emergency preparedness plan had not been identified on the HVA.

The following hazards were identified on the HVA with no accompanying strategy for response in the Emergency Preparedness (EP) plan:
1.) Sewer Failure
2.) Violence in the Hospital
3.) Indoor Air Quality Issues
4.) HVAC Failure
5.) Natural Gas/LP Failure
The following hazards had strategies for response in the EP plan, but were not identified on the HVA:
1.) Earthquake
2.) Nuclear/Radioactive Event
3.) Biological Event
4.) Chemical Event
In addition, the facility had not included "Emerging Infectious Diseases" to their HVA, with accompanying strategy for response as required by CMS's Quality, Safety and Oversight (QSO) letter dated February 1, 2019. (QSO19-06-ALL) When asked, the Nursing Coordinator stated the facility was aware the HVA needed some revisions and had planned on reviewing and updating the discrepancies on the HVA and the strategies for response in the EP plan. The Chief Nursing Officer stated the facility was unaware of the recent QSO letter and requirement to add emerging infectious diseases to the HVA and EP plan.

Reference:
42 CFR 482.15 (a) (1) - (2)

Based on record review and interview, it was determined the facility failed to provide a current policy for tracking on-duty staff during an emergency, to include the specific name and location of receiving facility or other location in the event they are relocated with patients during an emergency. Lack of a tracking policy has the potential to hinder the facility's ability to provide care and continuation of services during an emergency. This deficient practice had the potential to affect 7 patients, staff and visitors on the dates of the survey.

Findings include:

On April 16, 2019, from approximately 8:00 AM to 2:30 PM, review of the provided records, policies and procedures failed to demonstrate the facility had in place a system to track the location of on-duty staff during an emergency. When asked, the Nursing Coordinator stated the facility was unaware of the requirement to track on-duty staff during an emergency.

Reference:

42 CFR 483.73 (b) (2)

Based on record review and interview, it was determined the facility failed to implement an Emergency Preparedness (EP) training program. Failure to implement training on the EP plan, has the potential to hinder staff response during a disaster. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings include:

On April 16, 2019, from approximately 8:00 AM to 2:30 PM, review of the facility EP documentation revealed a written training plan, but there was no documentation that initial training for all new and existing staff, or individuals providing services under arrangement had taken place. While drills and exercises had been performed as required, interview of four (4) staff members on April 15, 2019, revealed they had not received specific training on the emergency plan or its contents. Interview of the Chief Nursing Officer confirmed the facility had not implemented their training program for Emergency Preparedness, to include initial or continuing education.

Reference:

42 CFR 483.73 (d) (1)

Based on record review, observation and interview, the facility failed to ensure Alcohol Based Hand Rub Dispensers (ABHR) were maintained in accordance with NFPA 101. Failure to test and document the operation of ABHR dispensers in accordance with the manufacturer's care and use instructions each time a new refill is installed could result in inadvertently spilling flammable liquids, increasing the risk of fires. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings include:

During review of facility maintenance records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, no documentation indicating ABHR dispensers are tested in accordance with manufacturer's care and use instructions when a new refill is installed could be produced. During the facility tour on April 15, 2019, from approximately 4:30 PM to 6:30 PM, ABHR dispensers were observed throughout the facility and when asked, the Maintenance Manager stated the facility was unaware of the testing requirement.

Actual NFPA standard:

NFPA 101

19.3.2.6* Alcohol-Based Hand-Rub Dispensers.
Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).
(2) The maximum individual dispenser fluid capacity shall be as follows:
(a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.53 gal (2.0 L) for dispensers in suites of rooms
(3) Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. (0.51 kg) and shall be limited to Level 1 aerosols as defined in NFPA30B, Code for the Manufacture and Storage of Aerosol Products.
(4) Dispensers shall be separated from each other by horizontal spacing of not less than 48 in. (1220 mm).
(5) Not more than an aggregate 10 gal (37.8 L) of alcohol-based hand-rub solution or 1135 oz (32.2 kg) of Level 1 aerosols, or a combination of liquids and Level 1 aerosols not to exceed, in total, the equivalent of 10 gal (37.8 L) or 1135 oz (32.2 kg), shall be in use outside of a storage cabinet in a single smoke compartment, except as otherwise provided in 19.3.2.6(6).
(6) One dispenser complying with 19.3.2.6 (2) or (3) per room and located in that room shall not be included in the aggregated quantity addressed in 19.3.2.6(5).
(7) Storage of quantities greater than 5 gal (18.9 L) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.
(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source
(b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source
(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source
(9) Dispensers installed directly over carpeted floors shall be permitted only in sprinklered smoke compartments.
(10) The alcohol-based hand-rub solution shall not exceed 95 percent alcohol content by volume.
(11) Operation of the dispenser shall comply with the following criteria:
(a) The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.
(b) Any activation of the dispenser shall occur only when an object is placed within 4 in. (100 mm) of the sensing device.
(c) An object placed within the activation zone and left in place shall not cause more than one activation.
(d) The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with label instructions.
(e) The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized.
(f) The dispenser shall be tested in accordance with the manufacturer's care and use instructions each time a new refill is installed.

Based on record review and interview, the facility failed to ensure the relative humidity in the operating room was maintained in accordance with CMS guidelines under nationally recognized standards. Failure to maintain relative humidity levels above twenty percent, could result in arc fires in the presence of increased static discharge. This deficient practice affected patients utilizing the Operating Room (OR), staff and visitors on the dates of the survey.

Findings include:

During review of OR temperature and Relative Humidity (RH) records conducted on April 15, 2019, from approximately 3:30 PM to 3:45 PM, records indicated RH in the OR dropped below 20% on 39 occasions between January 2, 2019 and April 15, 2019, an approximately 4-month time period. CMS S&C 13-25 dated April 19, 2013 states facilities must monitor RH in anesthetizing locations and take corrective actions when needed to ensure RH remains at or above 20 percent. When asked, the OR Nurse and Maintenance Manager stated the facility was aware of the low RH in the OR, but no corrective actions were taken to correct the deficiency. The Maintenance Manager further stated the facility's HVAC/ventilation system in the OR did not allow the facility to adjust RH.

Reference:

ASHRAE 170-2013

Based on observation, the facility failed to ensure safe electrical installations in accordance with their listed assemblies and those requirements under NFPA 70. Use of relocatable power taps (RPTs) outside of those defined in the referenced standard, UL 1363, has the potential to expose residents to risks of electrocution and arc fires. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings include:

During the facility tour on April 15, 2019, from approximately 4:30 PM to 6:30 PM, observation of installed electrical systems revealed the following:

1.) The copy machine located in the receptionist's area was plugged into an extension cord, that was also plugged into an extension cord, creating a "daisy chain".
2.) The full-sized refrigerator in the dining room was plugged into a Relocatable Power Tap (RPT). There was also a "zip" extension cord plugged in to the same RPT in the dining room, creating a "daisy chain".
When asked, the Maintenance Manager stated the facility was unaware of the extension cords and "daisy chains" in the building and he corrected the deficiency on the spot.

Actual NFPA standard:

NFPA 70

110.2 Approval. The conductors and equipment required or permitted by this Code shall be acceptable only if approved.

Informational Note: See 90.7, Examination of Equipment for Safety, and 110.3, Examination, Identification, Installation, and Use of Equipment. See definitions of Approved, Identified, Labeled, and Listed.

110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code Informational Note: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Special conditions of use or other limitations and other pertinent information. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(B) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Based on record review and interview, the facility failed to conduct fire drills in accordance with NFPA 101. Failure to conduct fire drills, one per shift per quarter, including the transmission of a fire alarm signal and simulation of emergency fire conditions, could result in confusion and hinder the safe evacuation of residents during a fire event. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings include:

1.) During review of facility maintenance records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, documentation revealed the facility failed to perform a fire drill on first shift, first quarter 2019. When asked, the Maintenance Manager stated the facility was unaware of the missing fire drill, but due to snow removal during this time frame, believed it was overlooked.

2.) During review of facility maintenance records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, documentation revealed a fire drill conducted on March 6, 2019 at 6:30 AM was simulated, without activation of the audible alarm. When asked, the Maintenance Manager stated the facility does not activate the audible alarm early in the morning and was unaware the alarm is required from 6:00 AM to 9:00 PM.

3.) During review of facility maintenance records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, review of provided fire drills revealed the facility was not conducting fire drills under varied conditions. This was systemic throughout the 2018 year.

Actual NFPA standard:

1./3.) 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
2.) 19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on observation and interview, the facility failed to ensure zone valves to the piped medical gas system were readily accessible outside of vital life-support areas. Failure to maintain access to zone valves has the potential to prevent shutdown of the piped gas system in the event of a fire or other emergency. This deficient practice affected patients utilizing the operating room, staff and visitors on the dates of the survey.

Findings include:

During the facility tour on April 15, 2019, from approximately 4:30 PM to 6:30 PM, observation of the surgical area and operating room revealed the piped medical gas system zone valve, located outside of the operating room on the adjoining wall, was blocked by a shelving unit that had been installed in front of it. There was no accessibility to the valve without moving the entire shelving unit and its contents. When asked, the Maintenance Manager stated he had never noticed it before and to his knowledge, the shelving unit had always been there.

Actual NFPA Standard:

NFPA 99

5.1.4.8.7 A zone valve shall be located immediately outside each vital life-support area, critical care area, and anesthetizing location of moderate sedation, deep sedation, or general anesthesia, in each medical gas or vacuum line, or both, and located so as to be readily accessible in an emergency.

Based on record review and interview, the facility failed to ensure positive pressure gas central piping systems and medical-surgical vacuum systems have a documented maintenance program. Failure to inventory, inspect, and maintain these systems, by a qualified person, could result in fire, explosion, or a lack of system performance as designed. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings include:

During review of facility maintenance records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, no documentation of a maintenance program for the positive pressure gas central piping systems and medical-surgical vacuum systems could be produced. When asked about the missing documentation, the Maintenance Manager stated the facility was unaware of this requirement, and to his knowledge, had never had a maintenance program for the piped gas and vacuum systems.

Actual NFPA standard:

NFPA 99
5.1.14.2.1* General. Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.
5.1.14.2.2 Maintenance Programs.
5.1.14.2.2.1 Inventories. Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets.
5.1.14.2.2.2* Inspection Schedules. Scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
5.1.14.2.2.3 Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment.
5.1.14.2.2.4 Maintenance Schedules. Scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
5.1.14.2.2.5 Qualifications. Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:
(1) Training and certification through the health care facility by which such persons are employed to work with specific equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional Qualification Standard for Medical Gas Systems Verifiers
5.1.14.2.3 Inspection and Testing Operations.
5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:
(1)*Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
(2)*Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems - delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks
5.1.14.2.3.2 Manufactured Assemblies Employing Flexible Connection(s) Between the User Terminal and the Piping System.
(A) Non-stationary booms and articulating assemblies, other than head walls utilizing flexible connectors, shall be tested for leaks, per manufacturer ' s recommendations, every 18 months or at a duration as determined by a risk assessment.
(B) The system pressure to non-stationary booms and articulating arms shall be maintained at operating pressure until each joint has been examined for leakage by effective means of leak
detection that is safe for use with oxygen.
(C) Safe working condition of the flexible assemblies shall be confirmed.
(D) D.I.S.S. connectors internal to the boom and assemblies shall be checked for leakage.
(E) Leaks, if any, shall be repaired (if permitted), or the components replaced (if required), and the equipment retested prior to placing the equipment back into service.
(F) Additional testing of non-stationary booms or articulating arms shall be performed at intervals defined by documented performance data.
5.1.14.3 Medical Gas and Vacuum Systems Information and Warning Signs.
5.1.14.3.1 The gas content of medical gas and vacuum piping systems shall be labeled in accordance with 5.1.11.1.
5.1.14.3.2 Labels for shutoff valves shall be in accordance with 5.1.11.2 and updated when modifications are made changing the areas served.
5.1.14.4 Medical Gas and Vacuum Systems Maintenance and Record Keeping. See B.5.2.
5.1.14.4.1 Permanent records of all tests required by 5.1.12.3.1 through 5.1.12.3.14 shall be maintained in the organization ' s files.
5.1.14.4.2 The supplier of the bulk cryogenic liquid system shall, upon request, provide documentation of vaporizer(s) sizing criteria to the facility.
5.1.14.4.3 An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity.
5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.
5.1.14.4.5 A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be implemented.
5.1.14.4.6 Whenever modifications are made that breach the pipeline, any necessary installer and verification test specified in 5.1.12 shall be conducted on the downstream portions of
the medical gas piping system.
5.1.14.4.7 Procedures, as specified, shall be established for the following:
(1) Maintenance program for the medical air compressor supply system in accordance with the manufacturer ' s recommendations
(2) Facility testing and calibration procedure that ensures carbon monoxide monitors are calibrated at least annually or more often if recommended by the manufacturer
(3) Maintenance program for both the medical-surgical vacuum piping system and the secondary equipment attached to medical-surgical vacuum station inlets to ensure the continued good performance of the entire medical-surgical vacuum system
(4) Maintenance program for the WAGD system to ensure performance
5.1.14.4.8 Audible and visual alarm indicators shall meet the following requirements:
(1) They shall be periodically tested to determine that they are functioning properly.
(2) Records of the test shall be maintained until the next test is performed.
5.1.14.4.9 Medical-surgical vacuum station inlet terminal performance, as required in 5.1.12.3.10.4, shall be tested as follows:
(1) On a regular preventive maintenance schedule as determined by the facility maintenance staff
(2) Based on flow of free air (Nl/min or SCFM) into a station inlet while simultaneously checking the vacuum level
5.1.15* Category 1 Maintenance. Facilities shall have a routine maintenance program for their piped medical gas and vacuum systems.
5.2 Category 2 Piped Gas and Vacuum Systems.
5.2.1* Applicability. These requirements shall apply to health care facilities that qualify for Category 2 systems as referenced in Chapter 4.
5.2.1.1 Section 5.2 through 5.2.12 shall apply to new health care facilities or facilities making changes that alter the piping. 5.2.1.2 Subsection 5.2.13
5.2.14* Category 2 Maintenance. Facilities shall have a routine maintenance program for their piped medical gas and vacuum systems.
5.3.13.4.2 A periodic testing procedure for Category 3 gas and vacuum systems and related alarm systems shall be implemented.

Based on record review and interview, the facility failed to ensure positive pressure gas central piping systems and medical-surgical vacuum systems are inspected and tested annually as part of a maintenance program. Failure to test and inspect these systems could result in fire, explosion, or a lack of system performance as designed. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings include:

During review of facility maintenance records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, no documentation for an annual inspection and testing of the positive pressure gas central piping systems and medical-surgical vacuum systems could be produced. When asked about the missing documentation, the Maintenance Manager stated the facility, to his knowledge, had never had the medical gas system and vacuum system inspected or tested.

Actual NFPA standard:

NFPA 99
5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.

Based on observation and interview, the facility failed to ensure the Essential Electrical System (EES) generator was equipped with a remote manual stop station in accordance with NFPA 110. Failure to provide a remote manual stop station has the potential to prevent shutdown of the emergency generator during a system malfunction, or unintentional activation/operation. This deficient practice affected 35 residents, staff and visitors on the dates of the survey.

Findings include:

During the facility tour on April 15, 2019, from approximately 4:30 PM to 6:30 PM, a remote manual stop station for the EES generator could not be located. When asked, the Maintenance Manager stated the facility was not equipped with a remote stop station.

Actual NFPA standard:

NFPA 99
6.4.1.1.16.2 Safety indications and shutdowns shall be in accordance with Table 6.4.1.1.16.2.
(SEE TABLE)

NFPA 110
5.6.5.6% All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

Based on record review, observation and interview, the facility failed to ensure non-hospital grade electrical outlets installed in patient care areas were maintained in accordance with NFPA 99. Failure to test these outlets at least every 12 months has the potential to limit the availability of reliable power and increases the risk for electrical fire. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings include:

During review of facility maintenance records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, documentation could not be produced to show non-hospital grade outlets in patient care areas were tested annually. Additionally, during the facility tour on April 15, 2019, from approximately 4:30 PM to 6:30 PM, observation of the patient care areas revealed non-hospital grade electrical outlets located in these areas. When asked, the Maintenance Manager stated the facility was not aware annual testing and documentation was required for non-hospital grade outlets in patient care areas.

Actual NFPA standard:

NFPA 99
6.3.4.1 Maintenance and Testing of Electrical Systems
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

Based on observation and interview, the facility failed to ensure the Essential Electrical System (EES) was installed in accordance with NFPA 99. Failure to provide an alarm annunciator for the EES could hinder early notification of equipment failures, leaving the facility without emergency power during an outage. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings include:

During the facility tour on April 15, 2019, from approximately 4:30 PM to 6:30 PM, observation of the facility revealed no alarm annunciator for the EES was present within the facility. When asked, the Maintenance Manager stated the facility did not have an alarm annunciator for the generator and was unaware one was required.

Actual NFPA standard:

NFPA 99
Chapter 6 Electrical Systems
6-4 Essential Electrical System Requirements - Type 1.
6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating
personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to warn of an engine generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in 6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

Based on record review and interview, the facility failed to ensure the generator for the EES (Essential Electrical System) was maintained in accordance with NFPA 110. Failure to inspect and test EES generators could result in a lack of system reliability and performance during a power loss. This deficient practice affected 7 patients, staff and visitors on the dates of the survey.

Findings Include:

1.) During review of the facility generator inspection and testing records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, the facility failed to provide weekly generator inspection logs for the following weeks:

a.) 4/15/18 - 4/21/18
b.) 8/5/18 - 8/11/18
c.) 8/12/18 - 8/18/18
d.) 8/19/18 - 8/25/18
e.) 9/2/18 - 9/8/18
f.) 1/13/19 - 1/19/19
g.) 1/20/19 - 1/26/19
h.) 1/27/19 - 2/2/19
i.) All of February 2019
j.) 3/3/19 - 3/9/19
k.) 3/10/19 - 3/16/19

Additionally, documentation of monthly load tests could not be produced for the following months:

a.) April 2018
b.) May 2018
c.) June 2018
d.) July 2018
e.) January 2019
f.) February 2019

2.) During review of the facility generator inspection and testing records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, the facility failed to provide documentation for a three-year, four-hour load test, as required by NFPA 110.

3.) During review of the facility generator inspection and testing records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, there was no indication the diesel fuel for the generator had been tested for quality during the annual inspection and maintenance of the generator as required by NFPA 110.

4.) During the facility tour on April 15, 2019, from approximately 4:30 PM to 6:30 PM, a remote manual stop station for the EES generator could not be located. When asked, the Maintenance Manager stated the facility was not equipped with a remote stop station.

When asked, the Maintenance Manager stated some weekly inspections and monthly load tests were missed due to the high volume of snow the facility received and the necessity to remove it promptly. He further stated the facility was unaware of the requirements for a three-year, four-hour load test, annual fuel quality test, annunciator panel or emergency stop station.

Actual NFPA Standard:

NFPA 110

1.) 8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

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

8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

2.) 8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.
8.4.9* Level 1 EPSS shall be tested at least once within every 36 months.
8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2).
8.4.9.2 Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours.
8.4.9.3 The test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining ATSs, or initiated by opening all switches or breakers supplying normal power to all ATSs that are part of the EPSS being tested.
8.4.9.4 A power interruption to non-EPSS loads shall not be required.
8.4.9.5 The minimum load for this test shall be as specified in 8.4.9.5.1, 8.4.9.5.2, or 8.4.9.5.3.
8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or
exceed the 30 percent requirement.
8.4.9.5.2 For a diesel-powered EPS, loading shall be that which maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
8.4.9.5.3 For spark-ignited EPSs, loading shall be the available EPSS load.
8.4.9.6 The test required in 8.4.9 shall be permitted to be combined with one of the monthly tests required by 8.4.2 and one of the annual tests required by 8.4.2.3 as a single test.
8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining
hour shall be at not less than 75 percent of the nameplate kW rating of the EPS.

3.) 8.3 Maintenance and Operational Testing.
8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

4.) NFPA 99
6.4.1.1.16.2 Safety indications and shutdowns shall be in accordance with Table 6.4.1.1.16.2.
(SEE TABLE)
NFPA 110
5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

Based on record review, and interview, the facility failed to ensure staff were trained in the risks associated with the storage, handling and use of medical gases. Failure to provide training of safety and risks associated with medical gases, hinders staff response and affects those patients utilizing supplemental oxygen. This deficient practice potentially affected three (3) patients utilizing oxygen, staff and visitors on the dates of the survey.

Findings include:

During review of provided facility training records on April 15, 2019, from approximately 9:30 AM to 4:30 PM, the facility was unable to produce documentation of a continuing education program for staff which includes periodic review of safety and usage requirements for medical gases. When asked, the Chief Nursing Officer and Maintenance Director stated the facility was unaware of the continuing education requirement. Due to training staff received on oxygen use and handling upon hire, the facility believed they were in compliance.

Actual NFPA standard:

NFPA 99
11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel.
11.5.2.1.1% Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be
trained on the risks associated with their handling and use.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel.
11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders.