HospitalInspections.org

This REQUIREMENT is not met as evidenced by:

Based on records review and interview with facility Director of Support Services surveyors 39983 and 16732 on 10/16/18, in the presence of the Director of Support Services the following was not met:

1. The facility failed to provide an emergency plan that includes the policies and procedures for the provision of subsistence needs including, but not limited to, food, water and pharmaceutical supplies for patients and staff.

This REQUIREMENT is not met as evidenced by:

Based on records review and interview with facility Director of Support Services surveyors 39983 and 16732 on 10/16/18, in the presence of the Director of Support Services the following was not met:

1. The facility failed to have written plan to track the location of on-duty staff and sheltered patients in the hospital's care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the hospital must document the specific name and location of the receiving facility or other location.

This REQUIREMENT is not met as evidenced by:

Based on records review and interview with facility Director of Support Services surveyors 39983 and 16732 on 10/16/18, in the presence of the Director of Support Services the following was not met

1. Facility failed to have a written plan for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.

This REQUIREMENT is not met as evidenced by:

Based on records review and interview with facility Director of Support Services surveyors 39983 and 16732 on 10/16/18, in the presence of the Director of Support Services the following was not met:


1. The facility failed to have a written plan for the use of volunteers in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

This REQUIREMENT is not met as evidenced by:

Based on records review and interview with facility Director of Support Services surveyors 39983 and 16732 on 10/16/18, in the presence of the Director of Support Services the following was not met:

1. The facility failed to have a written plan and police for the role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

This REQUIREMENT is not met as evidenced by:

Based on records review and interview with facility Director of Support Services surveyors 39983 and 16732 on 10/16/18, in the presence of the Director of Support Services the following was not met:

1. Communication plan. The hospital failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following:
(1) Names and contact information for the following:
(2) Staff
(3) Entities providing services under arrangement
(4) Patients' physicians
(5) Other hospitals and CAHs
(6) Volunteers

This REQUIREMENT is not met as evidenced by:

Based on records review and interview with facility Director of Support Services surveyors 39983 and 16732 on 10/16/18, in the presence of the Director of Support Services the following was not met:

1. Training and testing. The hospital failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.

This REQUIREMENT is not met as evidenced by:

Based on records review and interview with facility Director of Support Services surveyors 39983 and 16732 on 10/16/18, in the presence of the Director of Support Services the following was not met:

The facility failed to:

(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.

Based on observations surveyors 35163 and 37695 on 10/16/18, in the presence of the maintenance director the following was not met;


1. An unprotected wood frame building addition used for waste storage, is attached to backside of the hospital. It is not sprinklered and construction is V000 (unprotected wood frame)


37696

Based on observations by inspectors 37696 & JM and a Maintenance Employee, this has not been met due to the following.

The drawings provided to show the locations of rated separation did not match the actual construction of the building. In some instances it was not clear which way the rated wall turned or where it terminated.

The 2 hour rated wall was inspected following the plans provided. It was found however where the drawings showed a 2 hour rated wall the following issues were found:

1) along the staff lounge between at the bathroom, only a single layer of drywall was found

2) door to employee break room is not rated nor latching

3) the double door between compartment 2&4 by med storage has a 45 minute rated door in e a 90 minute rated frame

4) at the above location you could see exposed 2x wood framing at the cut edge of the b-deck as well as open penetrations

5) a single layer of drywall was seen at the wall at the double doors into the ED by the mechanical room. The door frame measured 7" which would also support the presumption only a single layer of drywall was used.

6) outside CT scan area the 2 hour wall identified on the plans however there was no door in the door opening

7) the clean storage room by CT scan 2 large rectangular opening with copper pipe running through the wall

8) top edge of wall is raw drywall and not sealed. One can stick their fingers down the back side of the drywall (single layer)

9) in cardiac rehab, plans show a 2 hour rated wall. Supposed 2 hour rated wall is built with a single layer of drywall and the top edge is unfinished and not sealed. A 4"x4" open penetration was found as well.

Based on record review and interview of surveyors 16732 and 39983 on October 16th 2018

1) The door inspection program that the facility has only 7 inspection points. This does not meet the criteria of the annual fire door assembly inspection and testing in accordance with 2010 NFPA 80 Edition

The facility director was present during this review.


2) A mirror is on the corridor wall at the intersection of the boiler room entrance and the dietary manager door that is below head height of 6 feet 8 inches and protrudes into the corridor more than 4 inches

The maintenance worker was present during this observation



35163

Based on observations surveyors 35163 and 37695 on 10/16/18, in the presence of the maintenance director the following was not met;

1. Pedestal/floor fan was located in the egress path/ corridor in OB wing.

2. Storage/display cabinet located in OB wing was in egress path/corridor.

3. Medical/surgical wing had Blood pressure carts being stored in the halls

4. OB wing near room # 251 had storage in the corridor ( TV cart, housekeeping cart and soiled linen).

5. Bench located in OR corridor near locker rooms decreased the corridor width to 4 feet and creates an obstruction to egress

6. Service entrance/exit had storage in the egress path ( 64 gallon recyclable container, 30 gallon trash container and a wheeled cart for cardboard.

Based on observations and interviews surveyors 35163 and 37695 on 10/16/18, in the presence of the maintenance director the following was not met;


1. Two doors located in the Operating room wing have deadbolt locking devices on the doors that could impede egress. Upon interview with staff they advised the locks were used for security reasons after hours when procedures and staff are not in the area.

Based on observation of surveyor's 37695 and 35163:

1) The house keeping closet door located next to the double set of fire doors, in the Med Surge West wing, contains a louver vent. The vent is open to the corridor and will not resist the passage of smoke in the event of a fire. This was found in the presence of the maintenance department.



2) The ultrasound rated fire door on a self closing device was propped open with a kick stop attached to the door

Based on record review and interview by surveyors 16732 and 39983 on 10/16/18

The emergency lights have not had annual testing of at least 1-1/2 hour duration


The facilities director was present during this observation and interview

Based on observation by surveyor 16732 on October 16, 2018


1) The boiler room has two round penetrations on the wall behind the boilers that are not sealed


2) Alcove near cardio waiting area used for photocopying, has 17 cases of photocopy paper stored open to hallway and not in a hazardous room.

The maintenance worker was present for these two observations.


35163

Based on observations surveyors 35163 and 37695 on 10/16/18, in the presence of the maintenance director the following was not met;

1. Emergency Department I/T-mechanical room is listed as a one hour fire rated room. The ceiling is a the drop ceiling assembly is not fire rated.

2. I/T room located in emergency Department has fire rated frame, but no fire rated door (door #133)

3. Medical gas bulk tank/manifold room had penetrations in 1 hr wall and ceiling with no fire stopping material present and had a non fire rated plywood back plate behind the manifold

Based on observations surveyors 35163 and 37695 on 10/16/18, in the presence of the maintenance director the following was not met;

1. The x-ray on call sleeping room did not have audio visual device that is connected to the fire alarm system.

Based on observation of surveyor 16732 on October 16, 2018

Sprinkler head is obstructed by light on ceiling in cardio waiting room


The maintenance worker was present during this observation


35163

Based on observations surveyors 35163 and 37695 on 10/16/18, in the presence of the maintenance director the following was not met;

1. Above ASU nursing station the vaulted ceiling/skylight does not have adequate sprinkler protection.

2. Mechanical space/closet located in x-ray #2 did not have sprinkler protection.

3. Mechanical space/closet located adjacent to lab chemical storage room did not have sprinkler protection and was missing ceiling tiles.





37695

Based on observation of surveyor 37695 and 35163:

1) The closet located in the office behind the nurse's station in the Med Surge West wing does not contain a sprinkler head. This was found in the presence the maintenance department.

2) The attached storage building located on the back of the facility near the employee/service entrance door does not contain sprinkler coverage. This was found in the presence of the maintenance department.

Based on observations surveyors 35163 and 37695 on 10/16/18, in the presence of the maintenance director the following was not met;

1. Storage room located in west medical surgical wing had a linen cart within 18" of the sprinkler head and would not allow for proper sprinkler pattern development.

2. CT scan room had two sprinkler heads with gaps around the escutcheon plates

Based on observations surveyors 35163 and 37695 on 10/16/18, in the presence of the maintenance director the following was not met;

1. House keeping closet located across from room # 231 has a louvered vent in the door that would not prevent the passage of smoke.

2. Sliding patient room doors located in west medical surgical wing do not have latching mechanisms.

3. Double 90 fire rated minute doors located between Emergency department and radiology lab have several penetrations and repairs to the doors. No documentation could be provided to indicate the repairs on the doors were done per manufacturers recommendations or per NFPA 80 requirements.









37695

Based on observation of surveyor 37695 and 35163:

1) The house keeping closet door located across from the emergency department directors office does not self close and positive latch. This was found in the presence of the maintenance department.

2) The fire rated double doors located near the emergency department directors office do not self close. The doors also have a gap greater than the allowable tolerance. This was found in the presence of the maintenance department.


Based on observations by inspectors 37696 & JM and a Maintenance Employee, this has not been met due to the following:

1) library door was propped open with a trash can

2) double doors to trash room at service entrance do not latch

Based on observations by inspectors 37696 & JM and a Maintenance Employee, this has not been met due to the following.

The drawings provided to show the locations of rated separation did not match the actual construction of the building. In some instances it was not clear which way the rated wall turned or where it terminated.

The rated smoke barrier had many penetration and intersection issues. Below are examples of violations found. Based on what was observed, it is presumed there are other sections along the rated barrier with similar violations.

1) Over the doors between compartment 1&2 near patient room 259:
on compartment 1 side, open penetrations with 3 wires running through it as well as multiple pieces of scabbed on drywall that were not sealed from compartment 2 side, cracked drywall over group of cables, no sealant around copper pipes.

2) Rm 259 at smoke barrier wall, spray foam was used to seal the rated barrier where the interior wall meets the exterior wall

3) Rated barrier between compartment 1 & 2 runs along the corridor. The drywall of the rated barrier wall is not continuous to the under side of the stops roughly 10" above the acoustical ceiling

4) Sprinkler pipe sealed with spray foam by reception next to lab waiting. An open penetration was found over the double door in this location

5) The top of the rated wall at the roof deck is not sealed. There was mineral wool and partial rated sealant however it was not completely sealed

Based on observations by inspectors 37696 & JM and a Maintenance Employee, this has not been met due to the following.

The drawings provided to show the locations of rated separation did not match the actual construction of the building. In some instances it was not clear which way the rated wall turned or where it terminated.

Although the doors in a smoke barrier are not required to latch, the plans provided showed that the smoke barrier was in fact a 1 hour rated smoke barrier. As a 1 hour rated wall, the doors should be self-latching. It was found that the cross corridor doors next to the library had one door leaf that did not latch.

Based on observation of surveyor 37695 and 35163:

The generator fuel supply tank does not contain any markings. Tanks containing flammable liquids must be marked with the appropriate placards displaying information regarding the contents of the tank. This was found in the presence of the maintenance department.

Based on record review of survryors 16732 and 39983 on October 16th, 2018

The 3rd shift fire drills for 2018 are not being held at unexpected times and under varying conditions. All 3 have happened between 0603am and 0629am.

The facility director was present during this observation

Based on observation of surveyors 37695 and 35163 on September 17th, 2018 the design and construction of the oxygen storage room is not correct with evidence as follows:

The storage room door was not locked. NFPA 99 2012 Edition Section 5.1.3.3.2 (2) They shall be secured with lockable doors or gates or otherwise secured



The maintenance department was present during his observation

Based on observations surveyors 35163 and 37695 on 10/16/18, in the presence of the maintenance director the following was not met;

1. Bulk storage of medical gas tanks located outside behind the gated encloure did not have proper signage

2. Medical gas tanks being stored in outside gated enclosure are not protected from the weather