HospitalInspections.org

Based on review of facility documentation and interview, it was determined the facility failed to include names and contact information for staff, patient physicians, volunteers and entities providing services under arrangement in the facility communications plan. Failure to provide contact information that could be needed during an emergency event in the facility communication plan can result in vital services being interrupted during an emergency event for staff and patients.

Findings include:

The Wickenburg Community Hospital Communications Plan was reviewed but no names or contact information could be found, nor could reference be found for how to access or locate, names and contact information for staff, patient physicians, volunteers and entities providing services under arrangement in the facility communications plan.

In an interview conducted with Employees #24 and 33 conducted on April 30, 2025, both Employees #24 and 33 confirmed that the entire communication plan including attachments had been provided.

Based on interview, review of facility emergency preparedness plan and review of facility documentation, it has been determined the facility failed to ensure each personnel member has been trained at hire and at least every two (2) years in emergency preparedness policies and procedures. Failure to ensure staff are trained both at hire and at least biennially on facility emergency preparedness policies and procedures can result in staff being unprepared in an emergency event, leading to increased likelihood of staff and patient injury or death.

Findings include:

Wickenburg Community Hospital Emergency Preparedness Plan indicated: "...All Wickenburg Community Hospital and Clinic (WCH) staff attend a Safety Training presentation upon hiring, and a refresher course every year thereafter....."

Documentation was requested of evidence of training of Wickenburg Community Hospital staff both at hire and annually. The documentation could not be provided.

In an interview conducted with Employee #1 on April 30, 2025, Employee #1 stated the emergency preparedness training program is currently being revised and provided a sample of the revised curriculum; however, documentation of transcripts or other evidence of training provided to staff either at hire or annually could not be provided.

Based on interview, review of facility policies and procedures, and review of facility documentation, it has been determined the facility failed to ensure that a full-scale drill was conducted at least every two years followed by either a subsequent full-scale drill the following year, or else a community-based drill, functional drill, mock disaster drill, tabletop drill or real-life emergency that required activation of the facility emergency preparedness plan and the documentation of the curriculum, after-action report and documentation of a sufficient number of staff attendance retained. Failure to adequately test and document the testing of the emergency preparedness plan can result in the facility having a plan that is not actionable or practicable in a real-life disaster event, leading to increased likelihood of staff and patient injury or death.

Findings include:

Wickenburg Community Hospital Emergency Preparedness Plan indicated: "...Wickenburg Community Hospital and Clinics test their emergency plans as required by State and Federal regulations. WCH will conduct exercises to test the emergency plan twice per year...Analyze the facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the facility's emergency plan, as needed....."

Documentation of disaster drills conducted throughout calendar years 2023, 2024 and 2025, including all accompanying documentation were requested. No documentation of disaster drills completed in 2023 could be provided.

One (1) disaster drill was completed in 2024 which included curriculum, an after-action report and signed attendance sheets indicating the participation of three (3) departments of the hospital encompassing a total of fourteen (14) staff.

Curriculum was provided for participation in a community disaster drill in 2025; however, no after-action report could be provided and no documentation of attendance by any individuals from Wickenburg Community Hospital could be provided for this drill.

In an interview conducted with Employee #24 conducted on April 30, 2025, Employee #24 confirmed that no additional documentation could be provided.

Based on observation while on tour and interview, it was determined the facility failed to ensure that there were two separate accessible emergency exits available from the mobile MRI unit. Failure to ensure two separate accessible exits from a mobile MRI unit can result in staff or patients being trapped in a fire event, leading to increased likelihood of injury or death.

NFPA 101 (2012) Chapter 19, Section 19.2.4.3. "Not less than two separate exits shall be accessible from every part of every story."

Findings include:

During observation while on tour conducted on April 29, 2025 while touring the mobile MRI unit, Compliance Officer requiested that a locked door be unlocked for further inspection. Beyond this locked door was an additional room containing a designated emergency exit. This emergency exit was locked and bolted shut with a bar that could not be easily removed. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 confirmed the emergency exit was not currently in use.

Based on observation and review of facility documents, it was determined the facility failed to ensure the hazardous areas have the doors be self-closing or automatic closing. Failing to maintain the self-closing hardware on the door and frame to a hazardous room has potential to cause harm to patients in time of a fire if the door does not latch and close.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing."

Findings Include:

During observation while on tour conducted on April 28, 2025 and on April 29, 2025, a room with a sign indicating the room as a biohazard room located in the hallway next to the community room area was noted to have a door that did not have a listed rating on the door.

On April 29, 2025, the door was observed to be left open during the day. The door did not have a lock on it so the door could be secured.

Inspections of fire doors and smoke doors completed July and August, 2024 by Employee #24 were provided. The biohazard door was not included within these provided inspection documents.

Based on observation while on tour conducted on April 28, 2025, it was determined the facility failed to ensure that a restraint chain was appropriately installed on the kitchen oven in order to protect the gas connection and that exhaust hoods were inspected and cleaned on a semi-annual basis. Failure to protect connections on appliances that are on casters or wheels can result in a rupture of gas or electric connections, resulting in risk of fire events. Failure to inspect and clean exhaust hoods for commercial kitchen equipment can result in grease build-up and/or system malfunction, leading to a fire event.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations...."

NFPA 96, 2011 Edition, Chapter 2, Section 2.1, "The documents or portions thereof listed in this chapter are referenced within this standard and shall be considered part of the requirements of this document...NFPA 54, National Fuel Gas Code, 2009 Edition...."

NFPA 54, 2009 Edition, Chapter 10, Section 10.12.6. Use with Casters. Floor-mounted appliances with casters...shall be installed in accordance with the manufacturer's installation instructions for limiting the movement of the appliance to prevent the strain on the connection.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 11, Section 11.2 Inspection and Testing, and Maintenance of Fire extinguishing Systems. Section 11.4 Inspection for grease buildup The entire exhaust system shall be inspected for grease buildup by properly trained, qualified; and certified persons acceptable to the authority having jurisdiction and in accordance with Table 11.4. Systems serving moderate -volume cooking operations Inspection frequency semi-annually...Systems serving low-volume cooking...annually."

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... "Chapter 11, Procedures for the use , Inspection, Testing, and Maintenance of Equipment. Section 11.2 "Maintenance of the fire extinguishing systems and listed exhaust hoods containing a constant or fire activated water system that is listed to extinguish a fire in the grease removal devices hood exhaust plenums and exhaust ducts shall be made by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction at least 6 months."

Findings include:

During observation while on tour on April 28, 2025, an oven was observed in the kitchen that was on casters (wheels). This oven did not appear to have a restraint chain or any other restraint apparatus that would prevent strain on the gas connection. In an interview conducted on April 28, 2025 with Employee #24, Employee #24 confirmed there was no restraint chain or any other restraint apparatus on the oven.

During observation while on tour on April 28, 2025, an oven in use in the rehabilitation therapy area was observed that had an operating exhaust hood. In an interview conducted with Employee #24 on April 28, 2025, Employee #24 confirmed the oven was in use and operational and was used for occupational therapy with patients.

Documentation was requested for semi-annual cleaning and inspection of fire systems for the kitchen range and hood observed in the commercial kitchen seen while on tour on April 28, 2025 and documentation was requested for annual cleaning and inspection of the exhaust hood located in the rehabilitation area.

Documentation was provided for one semi-annual cleaning of the commercial kitchen hood conducted on October 15, 2024. One inspection of fire systems on the hood was conducted on August 23, 2024 and a deficient item was noted. Documentation of the correction of the deficient item was requested but could not be provided. In an interview conducted with Employee #24 on April 30, 2025, Employee #24 stated that the cleanings and inspections on the commercial hood had been conducted semi-annually but the documentation had not been retained by the facility and could not be provided.

No documentation could be provided of any inspections or cleanings of the rehabilitation exhaust hood. In an interview conducted with Employee #24 on April 20, 2025, Employee #24 confirmed that this exhaust hood had not been inspected or cleaned since installation.

Based on observations and staff interviews, the facility failed to ensure monthly and annual testing for the fire alarm control panel in the mobile MRI unit. Failure to test the fire alarm system could cause harm to staff and residents during an emergency.

This is a repeat deficiency from Event ID #93JH22, February 25, 2022.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use". NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, "The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system". Chapter 26, Section 26.3.5.2.2 "The subsidiary facility shall be inspected at least monthly by central station personnel for the purpose of verifying the operation of all supervised equipment, all telephones, all battery conditions, and all fluid levels of batteries and generators". NFPA 72, National Fire Alarm and Signaling Code, Section14.6.2.1, Records shall be retained until the next test and for 1 year thereafter. CMS requires 3 years.

NFPA 72 Chapter 14, section 14.2.5 Releasing Systems.
Requirements pertinent to testing the fire alarm systems initiating fire suppression system releasing functions shall be covered by 14.2.5.1 through 14.2.5.6. and must be inspected in accordance with section 14.3 Inspection which requires Monthly and Annual inspection and service.

Findings include:

During observation while on tour conducted on April 29, 2025, a fire alarm control panel was observed behind a locked door in the mobile MRI unit. The FACP (fire alarm control panel) had a tag attached to it from Unifour Fire & Safety with an address in Hickory, North Carolina bearing an inspection date of June 22, 2021. The tag indicated the FACP was new and the expiration date of the inspection was twelve (12) months from the date punched on the inspection tag.

An interview was conducted with Employee #24 on April 29, 2025 who confirmed that a more recent inspection could not be provided for the FACP.

Based on observation while on tour, review of facility documentation and interviews, it was determined that the facility failed to ensure that escutcheons were maintained in order to appropriately cover annular spaces in accordance with NFPA 13. Failing to perform the required inspections may cause harm to patients and staff if sprinklers fail to function properly.

This is a repeat deficiency for Event ID #93JH22 February 25, 2022.

NFPA 101 Life Safety Code, 2012, 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." Section 9.7.1.1. "Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following...NFPA 13, Standard for the Installation of Sprinkler Systems...."

NFPA 13 (2010), Chapter 6, Section 6.2.7.1. indicated, "Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler."

Findings Include:

Observation while on tour conducted on April 28 and April 29 revealed the following:

-Ceiling penetrations around the escutcheon in the ladies' locker room;
-Escutcheon falling down around sprinkler in pharmacy storage;
-Missing escutcheon, sprinkler on administration stairwell;
-Utility hall closet, fire caulking applied around the exterior of a damaged escutcheon;
-Escutcheon hanging in case management office in acute care;
-Two (2) Escutcheon pulling away from ceiling away in lab;
-Two (2) Escutcheon with ceiling panels cracked around them in Radiology 2;
-Missing escutcheon, OR (operating room) storage;

A review of monthly maintenance reports indicated that visual inspections had been conducted and that no issues were reported. In an interview conducted on April 28, Employee #24 confirmed the escutcheons were not covering the annular spaces in accordance with NFPA 13.

Based on observation and staff interview, it was determined the facility failed to ensure that fire extinguishers were protected and properly installed. Failing to protect and have proper installation of fire extinguishers has potential to cause harm to staff and patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers."

NFPA 10, Section 6.1.3.7 "Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage." Section 6.1.3.8.1 "Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Section 6.1.3.8.2 "Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor."

NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility.

NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. NFPA 30 2012 edition 4.2.2 Combustible liquids Any liquid that has a closed cup flash point at or above 100 f as determined by the test procedures and apparatus set forth in section 4.4 NFPA 10 2012 edition 5.2.2 Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases. 6.3.1 Other Than for Fires in Flammable Liquids of Appreciable Depth. 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, except as modified by 6.3.1.5. Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards Type of Hazard ...Basic(moderate) ...Minimum Extinguisher Rating ...20-B ...Travel Distance to Extinguishers ...50 ft ...6.4.1 Fire extinguishers with Class C ratings shall be required where energized electrical equipment can be encountered.."

NFPA 10 2010 Edition, Chapter 5, Section 5.6.1. Where portable fire extinguishers are required to be installed, the following documents shall be reviewed for the occupancies outlined in their respective scopes...(16) NFPA 418, Standard for Heliports

NFPA 418 2011 Edition, Chapter 9, Section 9.1 The selection, installation, and maintenance of portable fire extinguishers shall comply with NFPA 10, Standard for Portable Fire Extinguishers. Section 9.2. At least one portable fire extinguisher as specified in Table 9.2 shall be provided for each takeoff and landing area, parking area, and fuel storage area.

Findings Include:

During observation while on tour conducted on April 28, 29 and 30, 2025, the following observations were detailed:

-When touring the mobile MRI (magnetic resonance imaging) unit, a portable fire extinguisher was observed on the ground beside the designated emergency exit.
-When touring the helipad, a purple K fire extinguisher was observed mounted on the wall enclosing the helipad. The fire extinguisher bore an inspection sticker indicating the fire extinguisher had been most recently inspected in 2023. The month of inspection was not legible as the sticker was worn. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 stated the facilities staff of Wickenburg Community Hospital was not responsible for inspecting or maintaining this extinguisher and the flight crew for the helicopter was responsible for maintaining it.
-When touring the vicinity of the helipad, a fuel tank was observed for the helipad. A fire extinguisher was observed beside the fuel tank for the helipad sitting on the ground that was unmounted.
-When touring the diesel generator, no fire extinguisher could be located within 50 feet of the generator housing. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 confirmed there was no fire extinguisher within 50 feet of the generator
-When touring the electrical room housing ATS (automatic transfer switches) and circuit boxes, no fire extinguisher could be found.
In an interview conducted with Employee #24 on April 29, 2025, Employee #24 confirmed no fire extinguisher was in or around the electrical room.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "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.

Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage." In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

NFPA 70, 2011, Chapter 4, Section 406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess mounted receptacle shall effectively close the opening and seat against the mounting surface."


NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface."

Findings include:

Observation while on tour conducted on April 28, April 29 and April 30, 2025 revealed the following:

-Information systems room contained a receptacle that was missing a cover.
-Pharmacy contained a receptacle cover with a brown staining liquid that was dripping from the interior. In an interview conducted on April 28, 2025, Employee #24 stated that the pharmacy once had a hydrogen peroxide misting system and this caused the leakage but that there was no corrosion; however, the cause of the staining could not be explained.
-Electrical room contained many stored items including sandwich board signs, chairs, boxes, loops of CAT cable, construction materials, piping, ladders, rolling carts and electronic items. Some of these items were leaning on circuit boxes.
-One open junction box was observed in the medical vacuum room. A canister of diesel fuel and cardboard boxes were stored beside the medical vacuum.
-In the boiler room, electrical wiring was observed to be grounded to a pipe that was painted green. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 stated that this pipe was a natural gas pipe.

Based on record review and interview with staff, it was determined the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, Standard for Fire doors and Other Opening Protectives. Failing to properly inspect and test fire rated door assemblies in accordance with NFPA 80 annually could potentially cause risk of harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1* "Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 "Horizontal sliding , Vertically Sliding, and Rolling Doors."
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

During observation while on tour conducted on April 28 and April 30, 2025, the following findings were observed:

-Fire Doors next to Rehabilitation area, the passive leaf of the door did not independently latch.
-Fire Doors near information system would not freely latch
-Two rolling fire doors were observed in the pharmacy department, one of which (the larger door) had automatic closure and one did not have the ability of automatic closure.
-Fire door to acute hall closest to courtyard does not independently latch
-CT (computed tomography) room door had a door frame rated 1.5 hours but the door did not have a listed rating
-Radiology room 1 door was cracked

Fire door inspection reports were requested and inspection reports for fire doors dated July and August, 2024 completed by Employee #24 were provided. These inspection reports indicated the following: "...Does the active door leaf completely close when operated from the full open position...Yes...Does the inactive leaf close before the active leaf when a coordinator is used...Yes...Does the latching hardware operate and secure the door in the closed position...Yes...Are the doors, hinges, frame, hardware and threshold secure, alighned and in working order with no visible signs of damage...Yes...." In all instances where a double door was inspected, these were the answers provided in the inspection report. All doors were noted to be free of damage.

Based on observation while on tour and interview, it has been determined the facility failed to appropriately label medical gas piping. Failure to appropriately label medical gas piping can result in confusion or error.

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 5, Section 5.1.11.1 Pipe Labeling indicated: "...Piping shall be labeled by stenciling or adhesive markers that identify the patient medical gas, the support gas, or the vacuum system and include the following...Name of the gas or vacuum system or the chemical symbol per Table 5.1.11...Gas or vacuum system color code per Table 5.1.11...the operating pressure...Pipe labels shall be located as follows...At intervals of not more than 6.1m (20ft)...."

Findings include:

Observation while on tour conducted on April 28 and April 29, 2025 revealed the following:

-Unlabeled copper piping of the type that could contain medical gas was found in the boiler room. It is unknown what this piping contains.
-Multiple unlabeled copper pipes were found in the network room. In an interview conducted with Employee #24 on April 29, 2025, Employee #24 stated this piping contained medical gas.

Based on observation while on tour and interview, it has been determined the facility failed to ensure that power strips were provided strain relief or were permanently mounted if utilized in a patient care area. Failure to ensure that power strips are utilized appropriately can result in an increased likelihood of a fire event.

This is a repeat deficiency from Event ID #93JH22, February 25, 2022.

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.

State Operations Manual Appendix A Interpretive Guidelines §482.41(a)

The hospital must ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well-being of patients. This includes ensuring that routine and preventive maintenance and testing activities are performed as necessary, in accordance with Federal and State laws, regulations, guidelines, and manufacturer's recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities should be incorporated into the hospital's QAPI plan.

The hospital must be constructed and maintained to ensure risks are minimized for patients as well as for employees and visitors. Hospitals are expected to demonstrate how they are addressing important safety features in accordance with nationally recognized standards. Although the following items are expected to be addressed when applicable, the list is not all-inclusive.
Accessibility

o A hospital must ensure all buildings at all locations of the certified hospital meet State and Federal accessibility standards (e.g. Office of Civil Rights requirements). The requirements apply to the interior and exterior of all buildings.
Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as a reference for healthcare surveyors as they survey the physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation. If line-operated medical equipment is used in a patient care room/area, inside the patient care vicinity:
o UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly
o ...In non-patient care areas/rooms, other UL strips could be used with the general precautions.

NFPA 99, 2012 Edition Section 10.5.2.3.1 indicated: Adapters and extension cords meeting the requirements of 10.2.4 shall be permitted to be used. 10.2.4.2. Section 10.2.4.2.3. The cabling shall comply with 10.2.3. Section 10.2.3.5.1 Cord strain relief shall be provided at the attachment of the ppower cord to the appliance so that mechanical stress, either pull, twist, or bend, is not transmitted to internal connections.

Findings include:

Observation while on tour conducted on April 28, 2025 revealed the following:

-A power strip was observed to be dangling without support in the pharmacy area;
-A power strip was observed to be dangling without support in the Foundation office;
-A power strip was observed to be dangling without support in the administration offices;
-A power strip was observed to be dangling without suppoort behind the nurse's station in the acute patient care area;
-A power strip was observed to be sitting on a desk but in use in OR

In an interview conducted with Employee #24 on April 28, 2025, Employee #24 acknowledged the deficient practice but stated this had been a condition that was difficult to correct because the Facilities Department had felt this was a condition that should be corrected by IT (information technology) and IT felt this was a condition that should be corrected by Facilities so the corrections had not been made.

Based on observation and staff interview the facility failed to keep combustible material 5 ft away from oxygen storage. Failure to keep combustible material away from oxidizing gases could cause an increase to the fire load which could harm staff and patients.

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 11.3.2. Storage for nonflammable gases greater than 85 m3 (300 ft3) but less than 85 m3 (3000 ft3) at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3. Section 11.3.2.2. Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor. Section 11.3.2.3 "Oxidizing gases, such as oxygen and nitrous oxide shall be separated from combustibles materials by one of the following...Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Findings included:

During observation conducted while on tour on April 28, 2025, an oxygen storage room was observed in the cardiopulmonary section of the hospital. On entry, 52 canisters of oxygen were observed to be stored within the room. Twenty-seven (27) of the canisters were marked as being full or partially full and the rest were not known to be full or empty. Additionally, within the room were three (3) yellow canisters, one (1) silver canister labeled as empty and three (3) white canisters.

Cardboard boxes were stored within the room.

The deficient practice was acknowledged in an exit interview conducted on April 30, 2025.

Based on review of facility documentation and interview, it was determined the facility failed to ensure that continuing education in safety guidelines and usage of maintenance and operation of medical gas equipment was provided. Failure to ensure that continuing education is provided in the safety guidelines and usage of, maintenance and operation of medical gas and equipment can lead to errors in the use of medical gas, resulting in injury to patients and/or 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. 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 ont he risks associated with their handling and use. A.11.5.2.1.1. "Personnel" typically includes physicians, nurses, nursing assistants, respiratory therapists, engineers, technicians and others. 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.

Findings include:

Documentation of periodic continuing education provided to staff regarding the safe use, maintenance and operation of medical gas and equipment was requested for calendar year 2024. Employee #1 provided documentation of self-assessments completed by staff that indicated an assessment completed by individual staff and signed off by a preceptor who evaluated demonstration of the listed skills. Although these self-assessments were indicated as orientation self-assessments, Employee #1 indicated these self-assessments were completed annually. The self-assessments included Location of Oxygen, gas shut-off valves and Oxygen tank and safety.

In an interview conducted with Employee #1 on April 30, 2025, Employee #1 confirmed that documentation of ongoing education provided to employees regarding oxygen or other medical gases could not be provided other than these self-assessments that included oxygen. Documents of assessment of an employee's knowledge of other medical gases could not be provided.

Based on observation while on tour and interview, it has been determined the facility failed to ensure that flammable and/or combustible liquids were safely stored to prevent the likelihood of fire. Failure to ensure flammable and/or combustible liquids are safely stored can increase the likelihood of a fire event, leading to injury or death of patients and/or staff.

NFPA 99 (2012), Chapter 15, Section 15.3.1, "The storage and handling of flammable liquids or gases shall be in accordance with the following applicable standards...NFPA 30, Flammable and Combustible Liquids."

NFPA 30 (2012), Chapter 3, Section 3.3.4. For the purposes of this Code, a story of a building or structure having one-half or more of its height below ground level and to which access for fire-fighting purposes is restricted.

Chapter 4, Section 4.1.2., "The definitions and classifications of this chapter shall apply to any liquids within the scope and subject to the requirements of this Code." 4.2.2. Combustible Liquid. Any liquid that has a closed-cup flash point at or above 100°F (37.8C)....42.3 Flammable Liquid. Any liquid that has a closed-cup flash point below 100°F (37.8C)...and a Reid vapor pressure that does not exceed an absolute pressure of 40 psi....4.3.1. Flammable liquids...shall be classified as Class I liquids....

Chapter 9, Section 9.3.6. Class I liquids shall not be permitted to be stored in basements as defined in 3.3.4. Section 9.17.2. Liquids shall be separated from Level 2 and Level 3 aerosols in accordance with NFPA 30B, Code for the Manufacture and Storage of Aerosol Products. Section 9.17.3. Flammable and combustible liquids shall be separated from oxidizers by at least 25 ft....Section 9.17.4. Materials that are water-reactive...shall not be stored in the same control area with liquids.

Findings include:

During observation while on tour conducted on April 29, 2025, large quantities of stored liquids and aerosols were observed that were stored in a basement area in the boiler room. These items were not easily accessible and were not clearly labeled. Some of the items appeared to be lawn chemicals, paint and paint thinner, but the exact nature of the items could not be clearly deduced. 57 (fifty-seven) separate containers could be viewed without climbing down into the basement area.

In an interview conducted with Employee #24 on April 29, 2025, Employee #24 confirmed that the facility did have fireproof cabinets for the storage of combustible and flammable materials, but these were already in use for other stored materials.