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Based on staff interviews it was determined the hospital failed to ensure appropriate safety measures were put in place after they were made aware of a leak in the exhaust pipe (See Tag 144).

An Immediate Jeopardy was cited on 4/16/19 at 1:46 p.m. due to the compromise in patient and staff safety.

A. An Immediate Jeopardy (IJ) to Patient Right's (Care in a Safe Setting) was called on 4/16/19 at 1:46 p.m. due to the facility manager's knowledge of an exhaust leak from the generator servicing the East building and failure to take corrective action.

B. Harm or Potential Harm: The patients and staff located in the east building have been exposed intermittently to noxious fumes from the exhaust leak.

C. Immediacy: The likeliness of serious harm to occur to patients and staff is imminent if the generator servicing the East building has to be used for a prolonged length of time. The hospital, at the time of entrance, had not taken any measures to correct the exhaust leak.

D. An immediate Plan of Correction was received and sent to the State Agency Program Managers. It was accepted and the hospital abated the IJ on 4/17/19 at 5:01 p.m.

Based on document review, observation and staff interviews it was determined the hospital failed to make immediate emergency generator repairs servicing the East building after the Director of Facility Services became aware of an exhaust leak in the East building on 3/4/19. This failure exposed patients and staff to noxious fumes during generator load tests that could ultimately lead to patient and staff receiving carbon monoxide poisoning or possibly death.

Findings include:

1. A review of the hospital document titled Monthly Generator Log-2019 revealed that on 3/4/19 a weekly generator test was started at 3:11 a.m. and stopped at 4:34 a.m. for generator with EPU# DGE33818.

2. A review of the hospital document titled A1 Security LLC Incident Report revealed on 3/4/19 at 3:30 a.m. a fire alarm was activated. The document under the area listed for summary of incident states: "At 0330 Fire Alarms and automatic doors were tripped. A Code Red Announcement followed stating a Fire Alarm had been tripped on the second floor of the east tower near the Environmental Services offices. Security and all appropriate staff responded. HFD (Huntington Fire Department) responded and S/O (Security Officer) Lycans insured they made it to the appropriate destination. The Alarm was reset and silenced with no further action." Under the area listed for action taken the document goes on to state: "Security responded to Code Red, insured no one was injured, found no signs of fire, met with and escorted HFD, Alarm silenced and reset, Filed a Report, End of Report."

3. In an interview with the Director of Facility Operations on 4/16/19 at approximately 11:02 a.m. it was determined on 3/4/19 at approximately 3:30 a.m. the fire alarm was set off while a weekly generator test was being performed for the generator that services the East building. The HFD responded and it was discovered that the generator test had triggered the fire alarm. The Director of Facility Operations stated he was made aware of the incident when he arrived at work on the morning of 3/4/19. He stated after conducting some tests he was able to determine there was an exhaust leak from the pipes running from the generator that services the East building. He stated that he had been looking at ways to correct the problem but did not have an actual plan in place. When questioned about the fire alarm being disabled he stated he put the alarm back in service on 4/15/19 while the State Fire Marshall was on site. When asked why the fire alram was disabled, he was unable to answer the question. He stated, "I ordered carbon monoxide (Co2) detectors yesterday and had them sent overnight. He agreed the Co2 detectors had not been put up at the time of this interview.

4. An interview was conducted with the manager of the Behavioral Health Unit and with the Registered Nurse (RN) working the unit on 4/16/19 at approximately 10:35 a.m. During the interview it was determined that there were times that diesel fumes could be smelled on the unit.

5. An interview was conducted with Coordinator of Pulmonary Rehabilitation on 4/16/19 at approximately 10:45 a.m. During the interview it was determined that diesel fumes had been smelled in patient care areas.

6. In an interview with the Director of Safety on 4/17/19 at approximately 9:00 a.m. it was revealed that he was the chair of the Environment of Care (EOC) Committee. He stated the incident that occurred on 3/4/19 had not been reported in their last meeting that was held on 3/28/19.

7. A review of the hospital policy titled Life Safety Plan states under the paragraph titled Reporting Deficiencies that "Scheduled fire drills and false alarms will be monitored for deficiencies. Appropriate action will be taken for corrections and reported to the Environment of Care Committee."

8. In an interview with the Accreditation and Clinical Safety Officer and the Director of Quality and Accreditation on 4/16/19 at approximately 11:45 a.m. it was determined the East building does contain patient care areas. The sixth floor is the area where sleep studies are conducted. The fifth floor is a Skilled Nursing unit and the Infirmary. The fourth floor is the Behavioral Health unit. The third floor is the Mother-Baby unit. The second floor is where Cornerstone Hospital, a long-term Acute Care Hospital, rents space from St. Mary's Medical Center. The first floor is where Pediatrics and Pulmonary Rehabilitation is located and the ground floor is where the Dietician offices and Facility Operations offices are located. When questioned if patients on ventilators could be located on the second floor in Cornerstone Hospital, they both agreed that it was possible that patients on ventilators would be in that area of the building that was being serviced by the generator with the exhaust leak.

Based on record review and staff interviews it was determined the hospital was not maintained to ensure the safety of patients and failed to ensure the safety and well-being of patients by the proper maintenance of the physical plant (see Tag A 701). Facility census 332.


A. An Immediate Jeopardy (IJ) to the overall maintenance of the physical plant (Physical Environment) was called on 04/16/19 at 1:46 p.m. Interview with the Director of Plant Operations on 04/16/19 at approximately 10:51 a.m. revealed the facility had been aware of a potential issue with the emergency generator exhaust leaking into the East Building for approximately one (1) month. On 03/04/19 at approximately 3:30 a.m. a smoke/heat detector on the 2nd floor of the East building was triggered and later discovered to be caused by leaking exhaust fumes from the emergency generator. The exhaust pipe for the emergency generator is run through an interior chase in the East Building which travels approximately 5 floors of the East Building.

B. Harm or Potential Harm: With the current installation of the leaking emergency generator exhaust within the interior chase of the East Building, if the generator is activated by a power loss or routine testing, the potential for diesel exhaust fumes and smoke to continue entering the East Building exists. No monitoring of the potential exhaust leaks over the previous month had been initiated until 04/15/19.

C. Immediacy: Although the facility had been aware of the leaking generator exhaust for approximately one (1) month, no corrective action was initiated until the date of complaint on 04/15/19. At that time carbon monoxide detectors were ordered and initial discussion regarding replacing and rerouting the emergency generator exhaust piping was initiated. At the time of entrance Administration was not aware of the issue with the leaking generator exhaust.

D. An immediate Plan of Correction was received and sent to the State Agency Program Managers. It was accepted and the facility abated the IJ on 04/16/19 at 5:01 p.m.

Based on record review and staff interviews, it was determined that the facility failed to assure the safety and well-being of patients by maintaining the physical plant. Facility census 332.

Findings include:

1. Staff interviews on 04/16/19 at approximately 10:51 a.m. revealed the Facility Operations Director was aware of a potential issue with the emergency generator exhaust leaking into the East Building and had been aware of this issue for approximately one (1) month. No documentation that this issue was being addressed though the facility maintenance program was available for review.

2. Record review on 04/16/19 at approximately 5:01 p.m. revealed that an acceptable Plan of Correction had been approved for the initial abatement of the Immediate Jeopardy Condition caused by the emergency generator exhaust fumes entering the building. The facility had begun addressing a permanent fix to the emergency generator serving the East Building as contractors were on site fabricating a new exhaust system for the generator. The facility is also considering rewiring the East Building to the main facility emergency generator. As of the time of complaint survey exit, a permanent fix for the emergency generator had not been completed.

3. Interview on 04/16/19 at approximately 5:04 p.m. with the Facility Operations Director verified these findings. These findings were also acknowledged by the Vice President of Support Services at the exit interview on 04/17/19.