HospitalInspections.org

Based on record review, observation and interview the facility failed to ensure staff were trained on the procedures for the facility tracking system of staff and patients.

Findings:

Interview of facility staff showed the triage system utilized did not show the facility staff could demonstrate or show knowledge of the patient tracking system procedures used by the facility.

On 08/26/19 at 3:31 pm, one nursing facility Staff K was asked about the facility's tracking system. Staff K was unable to describe and demonstrate the patient tracking system used by the facility.

Based on record review and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed the role of the facility under the 1135 waiver declared by the president in accordance with section 1135 of the act in provision of care and treatment.

Findings:

Record review of the facility's Emergency Preparedness plan showed that the facility lacked a policy regarding the facility's roles under a 1135 waiver during a declared disaster.


On 08/26/19 at 2:30 pm, the surveyor asked Staff C and Staff D if the facility established policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff C and Staff D stated the facility had contact information and that was all that was needed. The surveyor explained and provided Staff C with example of the 1135 waiver documentation.

Based on record review and interview the facility failed to ensure annual and initial in-service training for staff, and individuals providing services under arrangement, on the emergency preparedness plan for four of 13 employee files.

Findings:

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

Staff H with the date of hire 03/10/15 had not received 2017-2018 annual in-service training for emergency preparedness plan.

Staff I with the date of hire 04/13/17 had not received 2017-2018 initial and annual in-service training for emergency preparedness plan.

Staff J with the date of hire 02/19/80 had not received 2018 annual in-service training for emergency preparedness plan.

Staff L with the date of hire 07/10/00 had not received 2018 annual in-service training for emergency preparedness plan.

On 08/26/19 at 11:19 am, the surveyor asked the facility for documentation of training in-service for new, existing staff members, and individuals providing services under arrangement/contract.

On 08/26/19 at 3:20 pm, the surveyor looked over training via computer with Staff E, Staff F and Staff G.
Staff H and Staff I both are contracted staff and do documentation was provided to show annual training was completed for emergency preparedness 2017-2018. The annual emergency preparedness documentation does not exist for Staff H, Staff I, Staff J and Staff L.

Based on observation and interview the facility failed to ensure egress pathway were clear at all times as required.

Findings:

On 08/26/19 at 2:37 pm the surveyor observed the emergency egress pathway from the staff break room located across the hall from the laboratory was blocked with pillows, boxes and a cot.

On 08/26/19 at 2:37 pm the surveyor asked staff A why the egress pathway was blocked with stored supplies. Staff A stated they were supplies used for when staff slept and the staff did not know it was an emergency egress pathway.

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

Findings:

On 08/26/19 at 3:11 pm the surveyor observed a deadbolt lock and a barrel latch on the conference room doors.

On 08/26/19 at 3:11 pm the surveyor asked staff A why there was a deadbolt and a barrel latch on the conference room doors. Staff A stated the deadbolt and barrel latch had been added for security but will be taken off to meet compliance.

Based on observation and interview the facility failed to ensure emergency powered lighting at each exit discharge as required.

Findings:

On 08/26/19 at 2:05 pm the surveyor observed lighting fixtures at the main entrance of the facility and no battery backed up emergency lighting fixtures.

On 08/26/19 at 2:05 pm the surveyor asked staff A if the existing lighting fixtures at the exit discharge area of the main entrance were wired to the generator. Staff A stated those lights were not wired to the generator. The surveyor explained to meet compliance there has to be emergency powered lighting at exit discharge to a public way which can be either generator powered or battery backed up emergency lighting at each facility exit discharge area.

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

Findings:

Record review showed the emergency room isolation room was tested by facility staff to be negative but there was no annual test and balance inspection to verify ASHRAE 170-2008 ventilatory standards were being maintained for minimum number of air exchanges per hour.

On 08/26/19 at 3:05 pm the surveyor asked staff A for the annual 2018, and 2017 test and balance inspection reports. Staff A stated they do not have them as they were not done but they will get it scheduled.

Based on observation and interview the facility failed to ensure smoke detectors were installed appropriately.

Findings:

On 08/26/19 at 1:15 pm the surveyor observed a smoke detector at the front entrance within three feet of an air diffuser.

On 08/26/19 at 1:15 pm the surveyor asked staff A why the smoke detector was installed within three feet of two air diffusers. Staff A stated it should not have been installed that close to an air diffuser and they will have it moved.

Based on record review and interview the facility failed to ensure electrical receptacles in patient care areas were tested annually as required.

Findings:

Record review showed the facility did not complete annual impedance testing to patient care area electrical receptacles to include ground pole retention testing for 2016, 2017, and 2018.

On 08/26/19 at 2:45 pm, Staff A was asked for the annual impedance (patient care area electrical receptacle) testing for 2017 and 2018. Staff A failed to provide the impedance testing documentation for the facility. The electrical receptacle impedance testing documentation does not exist.