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Based on record review and interview the facility failed to ensure annual and initial in-service training for new and existing staff, individuals providing on-site services under arrangement, and volunteers on the emergency preparedness plan for 25 (staff TTT, staff UUU , staff VVV , staff WWW, staff XXX, staff YYY, staff ZZZ, staff AAAA, staff BBBB, staff CCCC, staff DDDD, staff EEEE, staff FFFF, staff GGGG, staff HHHH, staff IIII, staff JJJJ, staff KKKK, staff LLLL, staff MMMM, staff NNNN, staff OOOO, staff PPPP, staff QQQQ and staff RRRR) of 56 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and initial in-service training for new and existing staff, volunteers, and individuals providing on-site services under arrangement for the following staff:


Staff TTT with the date of hire 05/12/08 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018-2019 on the facility emergency preparedness plan.

Staff UUU with the date of hire 05/30/99 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff VVV with the date of hire 07/18/11 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff WWW with the date of hire 06/20/16 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff XXX with the date of hire 02/23/09 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018-2019 on the facility emergency preparedness plan.

Staff YYY with the date of hire 04/22/91 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff ZZZ with the date of hire 05/02/16 had not received initial or annual in-service training for emergency preparedness emergency plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff AAAA with the date of hire 10/15/12 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018-2019 on the facility emergency preparedness plan.

Staff BBBB with the date of hire 02/27/12 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff CCCC with the date of hire 04/18/16 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff DDDD with the date of hire 07/18/16 had not received initial in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff EEEE with the date of hire 08/16/10 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff FFFF with the date of hire 09/22/14 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff GGGG with the date of hire 09/22/08 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff HHHH with the date of hire 03/09/15 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff IIII with the date of hire 12/13/98 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff JJJJ with the date of hire 08/26/13 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff KKKK with the date of hire 11/18/02 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff LLLL with the date of hire 10/19/15 had not received initial or annual in-service training for the facility emergency preparedness plan.

Staff MMMM with the date of hire 01/31/11 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2018 on the facility emergency preparedness plan.

Staff NNNN with the date of hire 02/12/08 had not received initial or annual in-service training for emergency preparedness plan. The employee training transcript only showed annual training for 2013 on the facility emergency preparedness plan.

Staff OOOO with the date of hire 10/15/18 had not received initial in-service training for the facility emergency preparedness plan.

Staff PPPP with the date of hire 08/27/18 had not received initial in-service training for the facility emergency preparedness plan.

Staff QQQQ with the date of hire 11/26/18 had not received initial in-service training for the facility emergency preparedness plan.

Staff RRRR with the date of hire 01/08/19 had not received initial in-service training for the facility emergency preparedness plan.


The emergency preparedness training records for initial and or annual in-service do not exist for Staff TTT, Staff UUU, Staff VVV , Staff WWW, Staff XXX, Staff YYY, Staff ZZZ, Staff AAAA, Staff BBBB, Staff CCCC, Staff DDDD, Staff EEEE, Staff FFFF, Staff GGGG, Staff HHHH, Staff IIII, Staff JJJJ, Staff KKKK, Staff LLLL, Staff MMMM, Staff NNNN, Staff OOOO, Staff PPPP, Staff QQQQ and Staff RRRR.

On 02/26/19 at 01:15 pm the surveyor requested OU Children's, OU Medicine and OU Edmond training transcripts of new and existing staff, volunteers, individuals providing on-site services under arrangement.
On 02/27/19 at 2:40 pm following review of the requested documentation, the surveyor explained to Staff RRR and Staff SSS that no evidence of initial and/or annual training documentation existed for some staff training on emergency preparedness. Both staff RRR and staff SSS stated the agency switched from a previous learning system. The transcripts provided to the surveyor reflect courses completed from 2014 to current. The surveyor asked Staff SSS for the facility process for training on emergency preparedness. Staff SSS provided a statement as requested regarding the training process for the agency. "OU Medicine provides both initial and annual training for employees related to Emergency Preparedness. The transcripts provided to the surveyor reflect courses completed From 2014 to current. Transcripts prior to 2014 are archived in a previous version of the learning management system. In 2017, there was a leadership decision to not provide an additional module for emergency preparedness due to no changes. In 2018 staff received an annual update and the 2019 module has been assigned." The surveyor was unable to verify that documentation existed prior to 2014. The emergency preparedness documentation did not exist for some staff.

Based on record review and interview, the facility failed to ensure the annual emergency generator fuel quality testing as required.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2015, 2016, and 2017, as the documents do not exist.

On 02/27/19 at 1:52 pm, Staff QQQ was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016, and 2017. Staff QQQ stated, annual emergency generator fuel quality tests will be done.

Based on observation and interview the facility failed to ensure each egress access door could be opened with only one action as required.

Findings:

On 02/28/19 at 11:47 am a thumb knob deadbolt was observed on door 2770 which would require two actions to open to access the egress corridor.

On 02/28/19 at 12:08 pm Staff QQQ stated the deadbolt would be taken care of and others in the facility corrected also.

Based on record review, observation and interview the facility failed to maintain not less than two approved exits for every corridor in accordance with sections 7.4 and 7.5.

Findings:

Record review showed the Edmond facility did not provide documentation indicating the approval of the undesignating of a protected fire rated north end second floor stairwell exit. The review showed original design plans but did not include any information stating the stairwell was not a designated exit.

On 03/28/19 at 2:02 pm on the north end east corner of the second floor of the facility the surveyor observed a stairwell door with a non-compliant "No Exit" sign. This was the only exit from the second floor north end corridor of the building without having to walk to the south end of the second floor. An oversized elevator serving the second floor is located on the opposite corridor. The surveyor asked staff NNN for the fire marshal, and OSDH Plan Review approval documentation for the undesignation of the second floor stairwell exit. Staff NNN stated it has been that way for years and they would look for the paperwork. The paperwork for approving the undesignation of the stairwell exit does not exist.

Based on observation and staff interview it was determined the facility failed to ensure emergency lighting of at least 1.5 hour duration was provided automatically in accordance with NFPA 101, 2012 Edition Chapter 7.9, and 19.2.9.1.

Findings:

Record review for Children's Hospital, Edmond Hospital and OU Medicine showed the facilities had no battery backed up emergency lighting testing documentation for 2017 or 2016 due to a software change which corrupted their data.

On 02/28/19 at 1:48 pm the surveyor asked staff XXXX what happened to the 2017 and 2016 documentation for the monthly/yearly testing of the battery backed up lighting. Staff XXXX stated they had a software change and they lost all of the electronic software data, and only have symbols/characters which can not be deciphered.

Based on record review, observation and interview the facility failed to ensure ASHRAE 170-2008 ventilatory standards were followed as required.

Findings:

Record review showed the specimen room containing the 10% buffered formalin solution containing methanol and formaldehyde was not included on the facility's annual test and balance inspection report so the ASHRAE 170-2008 ventilatory guidelines could not be confirmed for this area.

Record review showed the sterile core of the outpatient surgery center (located next door to the McGee Eye ASC) where sterile supplies are stored was not included on the facility's annual test and balance report to confirm the minimum number of air exchanges per hour and if the area was under positive pressure as required.

Record review showed the relative humidity (RH) levels for the outpatient surgery center (located next to the McGee Eye ASC) were below 20%RH for February 2019 with no documented corrective action being taken by facility staff.

Assembly Room Outpatient Surgery Center RH
02/12/19 8:05 am 16.6%
02/12/19 3:30 pm 15.9%
02/13/19 6:36 am 14.0%
02/15/19 6:15 am 12.1%
02/18/19 6:08 am 10.0%

Record review showed relative humidity levels for June 2018 in the Children's OR were consistently over 60% with no documented corrective action being taken by facility staff.

June 18, 2018
OR 11 RH
72.2%, 76.2%, 72.8%, 72.3%

June 19, 2018
OR 11
68.3%

Record review showed the facility did not submit plans to OSDH Plan Review for the approval of the specimen room for the storage of the 10% buffered formalin solution.

On 02/27/19 at 2:00 pm the surveyor observed a room with no signage between operating room 12 and 11 within the restricted sterile corridor which staff called the specimen room which had a 10% buffered formalin stored within it. The solution has methanol and formaldehyde which the safety data sheet directs to use adequate ventilation, do not breathe vapors or mists, prevent eye and skin contact. The safety data sheet further directs to refer to OSHA 1910.1048 which outlines exposure monitoring, and warning signage for formaldehyde. The room containing the specimen formula was observed to be a repurposed room in which the ventilation could not be confirmed and staff XXXX was asked for OSDH Plan Review approval for the room being repurposed into it's current configuration.

On 02/28/19 at 8:46 am the surveyor observed the sterile core of the outpatient surgical center had sterile supplies being stored on steel multi shelve racks.

On 03/01/19 at 9:05 am the surveyor asked staff XXXX what corrective action is taken when relative humidity readings are out of compliance. Staff XXXX stated they adjust the computer levels to lower or raise relative humidity but have a challenge due to the weather in addition to aging HVAC systems. Staff XXXX stated they would address documenting corrective action for out of compliance relative humidity levels.

Based on obsevation and interview the facility failed to ensure eletrical biomedical equipment was inspected before being placed into service.

Findings:

On 02/28/19 at 9:40 am the survyeor observed a Valley Lab Forest FX cautery machine without a current inspection sticker located at the outpatient surgery center near the McGee Eye ASC.

On 02/28/19 at 9:40 am staff QQQ stated he would get the equipment without a current inspection sticker on the list to be inspected.

Based on record review and interview, the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the fire drills for Edmond Hospital, Children's Hospital and OU Medicine for 2016 and 2017 did not document transmission of a fire alarm signal. The documentation of verification of a fire alarm signal for each individual fire drill for the different departments within the facility were not documented.

On 02/25/19 at approximately 11:17 am the surveyor stated to Staff XXXX the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff XXXX stated they would add that to the fire drill documentation.

Based on observation and interview the facility failed to ensure soiled biohazard waste was stored in protected hazardous areas as required.

Findings:

On 02/27/19 at 1:30 pm the surveyor observed three large waste containers stored in the egress corridor between patient rooms 425 and 426.

On 02/27/19 at 1:30 pm Staff Q was asked why the waste containers were stored open to the egress corridor. Staff Q stated it is because they have psych patients in the rooms and did not want to leave the trash cans in their rooms. The surveyor explained waste containers over 32 gallons cannot be stored open to the corridor within a 64 square foot area and should be stored in a protected hazardous room.

Based on record review and interview the facility failed to ensure electrical receptacles in operating room wet location were protected with GFCI or LIM as required unless electrical systems risk assessment was completed as required.

Findings:

Record review showed the facility had not completed an electrical systems risk assessment of the patient care related electrical receptacles located in Operating Rooms 19 and 20.

On 02/27/19 at 1:45 pm the surveyor observed OR 19 and 20 with no LIM or GFCI. OR 19 and 20 is surveyed as a wet location due to the nature of OB procedures being performed as advised by Staff QQQ. The surveyor asked Staff QQQ if the facility had completed a electrical systems risk assessment for OR 19 and 20. Staff QQQ stated he would check. Staff QQQ came back at a later time and stated the facility did not do a risk assessment for the areas.

Based on record review and interview the facility failed to ensure electrical receptacles in patient care areas were tested and had been placed on an outlined preventative maintenance program as required.

Findings:

Record review showed the facility had not tested the operating rooms line isolation monitors (LIM) or hospital grade electrical receptacles located in patient care areas. No LIM annual inspections were completed for 2016, 2017, and 2018. Record review showed the facility did not complete impedance testing to patient care area electrical receptacles to include ground pole retention testing for 2016, 2017, and 2018.

On 02/27/19 at 2:45 pm, Staff QQQ was asked for the LIM annual inspections and impedance (patient care area electrical receptacle) testing for 2016, 2017, and 2018. Staff QQQ stated the impedance testing was not completed but will be scheduled and completed ongoing. The electrical receptacle impedance testing and LIM annual testing documentation does not exist. The surveyor explained that if electrical receptacles in patient care areas are not hospital grade, testing is to be done annually. If they are hospital grade they are to be placed on a preventative maintenance program with periodic testing.

Based on record review and interview, the facility failed to ensure the annual emergency generator fuel quality testing as required.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2015, 2016, and 2017, as the documents do not exist.

On 02/27/19 at 1:52 pm, Staff QQQ was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016, and 2017. Staff QQQ stated the annual emergency generator fuel quality tests will be done.

Based on observation and interview the facility failed to ensure extension cords were not used as a substitute for fixed wiring, and the facility failed to produce manufactures documentation verifying power strips used in facility met UL 1363A or UL 60601-1 requirements.

Findings:

Record review showed no information confirming power strips used in operating rooms conformed to UL 1363A or UL 60601-1 requirements.

On 02/26/19 at 1:01 pm the surveyor observed an extension cord plugged into a television in the employee's lounge at Children's Hospital.

On 02/27/19 at 9:46 am the surveyor observed an extension cord daisy chained into a power strip in Operating Room 2.

On 02/27/19 at 9:46 am the surveyor requested documentation from staff XXXX confirming power strips conformed to CMS's requirements. Staff XXXX stated they would get the paperwork. The documentation was not provided as it did not exist.

Based on observation and interview the facility failed to ensure medical gases were properly stored and secured as required.

Findings:

On 02/26/19 at 2:10 pm the surveyor observed three, approximately liter sized non-secured liquid nitrogen cylinders in the medical gas room between Operating Room 11 and 12 directly off from the semi restricted corridor in the surgical suite.

On 02/26/19 at 2:10 pm staff XXXX stated the vendor advised them it was okay for the nitrogen cylinders to not be secured. The surveyor stated vendor statements do not usurp fire code complaince requirements of medical gas cylinders needing to be secured.


NFPA 99, 2012 Edition
11.3.2.6 Cylinder or container restraints shall comply with
11.6.2.3.
11.6.2.3 Cylinders shall be protected from damage by means
of the following specific procedures:
(11) Freestanding cylinders shall be properly chained or supported
in a proper cylinder stand or cart.