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Based on record review and interview, the facility failed to maintain an emergency preparedness plan that is reviewed annually and updated as needed. The deficiency affects the entire facility.

Findings include:

1. Review of the facility EP plan on 6/5/19, showed the facility EP plan did not have a date of completion or an annual review date.

2. During an interview on 6/5/19 at 11:56 a.m., staff member C stated the facility did not have documentation of an annual review of the facility EP plan and he stated the plan is a work in progress.

Based on record review and interview, the facility failed to develop, establish, and maintain a comprehensive emergency preparedness (EP) program that identifies all-hazards approach strategies for addressing the facility's vulnerability during emergency events. This affects all staff and patients of the facility. Findings include:

1. Review of the facility EP program on 6/5/19 at 11:50 a.m., showed the facility had not completed a risk assessment and the facility EP plan lacked pertinent information about the facility's internal and external vulnerabilities during an emergency event.

During an interview on 6/5/19 at 11:56 a.m., staff member C stated the facility is in the process of completing all required elements of their EP program.

Based on record review and interview, the facility failed to update, implement, and annually review emergency preparedness (EP) policies and procedures. This deficiency has the potential to affect all patients and staff of the facility. Findings include:

1. A review of the facility EP program on 6/5/19 at 11:51 a.m. showed, the facility's EP programs policies and procedures were incomplete and lacked annual reviews and updates.

During an interview on 6/5/19 at 11:57 a.m., staff member C stated the facility EP plan was in the process of being updated and many of the required components, including facility policies and procedures, were missing or incomplete at the time of the survey.

Based on record review and interview, the facility failed to plan and implement a provision of subsistence needs for the staff and the patients, whether they evacuated or sheltered in place. This affects all occupants in the facility.

Findings include:

Review of the EP plan, policies, and procedures on 6/5/19, showed the facility lacked a system for determining subsistence needs for staff and patients, particularly specific needs for water, medical and pharmaceuticals for the number of patients and staff who would be sheltering in place.

During an interview on 6/5/19 at 11:57 a.m., staff member C stated, "I know we don't have that", when asked to provide documentation regarding subsistence needs for staff and patients in the event of an emergency.

Based on record review and interview, the facility failed to develop, implement, and annually review emergency preparedness (EP) communications plan from 11/15/17 through 6/5/19. Findings include:

1. A review of facility policies and procedures on 6/5/19, reflected the facility lacked a completed EP communication plan.

During an interview on 6/5/19 at 11:58 a.m., staff member C stated the EP communication plan needed to be completed for the facility, and the information was missing in the system.

Based on record review, the facility failed to update as needed, an emergency preparedness communication plan. This deficiency has the potential to affect the entire facility. Findings include:

1. Review of the facility EP program on 6/5/19 at 11:01 a.m., showed the facility's communication plan lacked documentation of contact information for entities providing services under arrangement, patients physicians, other CAH's, and facility volunteers.

Based on record review, the facility failed to develop and implement emergency preparedness (EP) communications plan including contact information for Federal, State, tribal, regional, and local EP staff, and other sources of assistance. Findings include:

1. Review of the facility EP plan on 6/5/19 at 11:02 a.m., showed the facility's emergency preparedness plan lacked contact information for Federal, State, Tribal, Regional, and Local EP staff and other community sources of assistance.

Based on record review and interview, the facility failed to develop and maintain an EP training and testing program that is based on the facility's Emergency Preparedness plan. This deficiency has the potential to affect the entire facility. Findings include:

1. Review of the facility EP plan on 6/5/19 at 11:02 a.m. showed, the facility EP plan lacked documentation of testing and staff training of the facility EP plan.

During an interview on 6/5/19 at 11:59 a.m., staff member C stated he is responsible for the facility EP plan. He stated the facility EP plan is in the process of being updated and the training and testing of the facility EP plan has not yet been completed.

Based on record review and interview, the facility failed to implement annual training of the EP program to all staff members, including contractors, consistent with each team members' expected roles during an emergency or a disaster. This deficiency affects all staff and patients in the facility. Findings include:

1. Review of the facility EP plan on 6/5/19 at 11:05 a.m. showed, the facility lacked documentation of staff training on the facility EP plan.

During an interview on 6/5/19 at 12:00 p.m., staff member C stated he did not have documentation of staff training on file. He stated the facility is in the process of updating their EP program and staff training would be conducted once the plan updates were finalized.

Based on record review and interview, the facility failed to conduct a full-scale community-based (or a full-scale facility based) exercise, at least annually. This deficiency affects all staff and patients in the facility. Findings include:

1. Review of the facility EP plan on 6/5/19 at 11:07 a.m. showed a lack of evidence that the facility had conducted a full-scale community-based and/or facility-based exercise in the last year.

During an interview on 6/5/19 at 12:01 p.m., staff member C stated the facility had not completed a full-scale community-based or facility-based exercise in the last year. He stated the facility conducted a table top exercise on 5/8/19.

Based on record review and interview, the facility failed to develop an integrated and complete EOP (emergency operations plan), where the separately certified facility's unique circumstances, patient populations and other services are identified. This deficiency affects all of the patients and the staff in the facility.

Findings include:

A review of the hospital's EOP on 6/5/19 showed that facility was a part of a integrated healthcare system. However, the facility was not included in the EOP as an independently certified healthcare unit. The EOP policy and procedures were not developed separately to meet the needs and the unique circumstances of the hospital, its patients and staff. For example, the hospital did not have an individual community and facility based risk assessment utilizing all-hazards approach. Additionally, the EOP lacked a coordinated communication and training plan that would meet the unique needs of the hospital staff and the patients it served.

During an interview on 6/5/19 at 12:02 p.m., staff member C stated the facility did not have and integrated EOP which identified the unique circumstances, patient populations, and services the facility was able to provide in an emergency. He stated a documented community-based risk assessment, utilizing an all-hazards approach, had not been completed for the facility.

Based on observation, the facility failed to ensure the fire and smoke resistance rating of ceiling assemblies in a building of Type II (222) construction was maintained in accordance with NFPA 101-2012, Section 19.1.6.2. The deficiency affects the entire facility.

Findings include:

1. During an observation on 6/5/19 at 9:45 a.m., the clean laundry room was inspected. An unsealed penetration was observed in the ceiling tile of the room, with air conditioning lines passing through the tile.

2. During an observation on 6/5/19 at 9:58 a.m., the laundry room was inspected. An unsealed penetration was observed in the ceiling tile of the room.

3. During an observation on 6/5/19 at 10:17 a.m., patient room 133 was inspected. An unsealed penetration was observed in the ceiling tile of the room.

4. During an observation on 6/5/19 at 10:35 a.m., the two-hour firewall outside the lobby was inspected. An unsealed penetration was observed, a red cord and a white pipe penetrated through the wall.

5. During an observation on 6/5/19 at 11:02 a.m., the IT room was inspected. An unsealed penetration was observed with several IT cords penetrating through the ceiling tile in the room.

Based on observation and interview, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2. These deficiencies affect the entire facility. Findings include:

1. During an observation on 6/5/19 at 10:02 a.m., the bathroom adjoining patient rooms 137 and 138, was inspected. The bathroom doors were fitted with locks on the opposite side of the egress side. Locks like this could lock someone in the bathroom.

2. During an observation on 6/5/19 at 10:18 a.m., the emergency exit door, by patient room 133 was inspected. The emergency exit door would not open to the full required width of the opening in which it was installed, it was blocked from opening by a bar which restricted its opening capability.

3. During an observation on 6/5/19 at 10:38 a.m., the business office was inspected. The business office door was fitted with a deadbolt lock, separate from the latchset, and required more than one single action to operate the door.

4. During an observation on 6/5/19 at 10:43 a.m., the conference room was inspected. The conference room door was fitted with a deadbolt lock, separate from the latchset, and required more than one single action to operate the door.

5. During an observation on 6/5/19 at 10:44 a.m., the medical records office was inspected. The medical records door was fitted with a deadbolt lock, separate from the latchset, and required more than one single action to operate the door.

6. During an observation on 6/5/19 at 11:00 a.m., the quality assurance office was inspected. The quality assurance office door was fitted with a deadbolt lock, separate from the latchset, and required more than one single action to operate the door.

7. During an observation on 6/5/19 at 11:05 a.m., the marketing office was inspected. The marketing office doors were fitted with deadbolt locks, separate from the latchset, and required more than one single action to operate the doors.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7.

Findings include:

1. During an observation on 6/5/19 at 9:44 a.m., the clean laundry door was held open with a non-compliant door holder. The door also had a self-closure.

Based on observation and interview, the facility failed to ensure exit signs are displayed and illuminated either internally or externally in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1.

Findings include:

1. During an observation on 6/5/19 at 10:46 a.m., the medical records suite was inspected. No exit sign was observed near the emergency exit door leading into the main corridor.

Based on observation, the facility failed to maintain hazardous areas in accordance with NFPA 101-2012, Sections 19.3.2.1 and 19.3.2.1.3. This deficiency affects the entire facility.

Findings include:

1. During an observation on 6/5/19 at 9:56 a.m., the door to the laundry room was inspected. The door was fitted with a self-closer, but it disconnected from the wall, and the door failed to close and positively latch after being opened near full.

2. During an observation on 6/5/19 at 11:09 a.m., the lab was inspected. The door leading to the lab from the corridor was not fitted with a self-closer and would not close and latch without manual intervention.

Based on observation and record review, the facility failed to maintain the kitchen hood extinguishing system in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition, Section 11.2.1.

Findings include:

1. Record review of the kitchen hood extinguishing system reflected lack of documentation to show the contractor had performed services on a semi-annual basis. All documentation provided by the facility reflected the hood was inspected in September of 2018, but was not inspected in 2019, and was due for inspection in March of 2019.

Based on observation, interview and record review, the facility failed to:

a) provide documentation of completion of all the required automatic sprinkler system tests and inspections.
b) ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Sections 5.1.1.1 and Table 5.1.1.2.
c) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.
d) ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

These deficiencies affect the entire building.

Findings include:

1. A request for review of the facility's sprinkler testing and inspection reports on 6/5/19 at 8:00 a.m. revealed the facility was unable to provide documentation of a completed quarterly sprinkler system inspection for the fourth (4th) quarter of 2018. Further, the facility failed to have a sprinkler inspection within a 90-day time frame between the first (1st) and second (2nd) quarters of 2019.

Interview with the Maintenance assistant on 06/05/19 at 8:30 a.m. revealed the facility was aware of the missing and overdue quarterly sprinkler inspections.

Actual NFPA Standard: NFPA 25 (2011) Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
5.2.5 Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.
5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.
5.3.3.3 Testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector's test connection.
13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly.
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

2. Review of facility documentation for the automatic sprinkler system on 6/5/19 reflected a lack of five-year internal inspection for the wet sprinkler system.

3. During an observation on 6/5/19 at 9:49 a.m., the kitchen pantry was inspected. Air conditioner lines were observed lying on the wet sprinkler pipe.

4. During an observation on 6/5/19 at 9:53 a.m.., the kitchen was inspected. A sprinkler head was observed, covered in white paint.

5. During an observation on 6/5/19 at 9:57 a.m., the laundry room was found to have a sprinkler head that was loaded with dust and debris.

6. During an observation on 6/5/19 at 10:05 a.m., the storage room was inspected. A sprinkler head was observed, obstructed by a large box that was placed within 18 inches of the sprinkler head.

7. During an observation on 6/5/19 at 10:07 a.m., the storage room was inspected. Blue IT camera wires were observed connected to the wet sprinkler pipe.

8. During an observation on 6/5/19 at 10:52 a.m., the utility room in the north hallway was inspected. A sprinkler head was observed that was completely blocked by a large bath chair, placed on a shelf just under the sprinkler head.

9. During an observation on 6/5/19 at 11:03 a.m., the IT room was inspected. The room was found to have a sprinkler head that was obstructed by a light fixture. the hallway outside the X-ray room was found to have a sprinkler head obstructed by a light fixture.

10. During an observation on 6/5/19 at 11:23 a.m., the replacement sprinkler head box, next to the wet sprinkler riser, was inspected. The box contained six sprinkler head replacements, but no wrench was available to replace the sprinkler heads, in the event that a replacement was needed.

Based on observation, interview and record review, the facility failed to:

a) inspect portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2
b) maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

These deficiencies affect the entire building.

Findings include:

1. During an observation on 6/5/19 at 9:32 a.m., several portable extinguishers were inspected. None of the facility portable fire extinguishers had any initials on them as having been inspected monthly.

During an interview on 6/5/19 at 9:32 a.m., staff member B stated the facility maintenance staff did not perform monthly checks on the fire extinguishers in the facility.

2. During a review of the facility portable fire extinguisher report, dated 5-9-19, completed by Western States Fire Protection Company, the following items were discovered:

a) The portable fire extinguisher, located next to the Fire Alarm Panel, was overdue for its hydro inspection, the hydro inspection was due in 2017.
b) The portable fire extinguisher, located inside the lab, was overdue for its five-year inspection, the five year inspection was due in 2016.
c) The portable fire extinguisher, located inside the ambulance garage, was overdue for its hydro inspection, the hydro inspection was due in 2018.

3. During an observation on 6/5/19 at 10:38 a.m., the business office was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by several items being placed in front of it.

4. During an observation on 6/5/19 at 11:08 a.m., the lab was inspected. The portable fire extinguisher in the room was found to be blocked from instant access by several items being placed in front of it.

Based on observation, the facility failed to maintain corridor doors and to ensure a means suitable for keeping the doors closed in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.5. These deficiencies effect the entire facility.

Findings include:

1. During an observation on 6/5/19 at 10:08 a.m., the corridor door to resident room 135 was exercised. The door would not close and positively latch with a nominal amount of force placed on it.

2. During an observation on 6/5/19 at 10:19 a.m., the corridor door to resident room 131 was exercised. The door would not close and positively latch with a nominal amount of force placed on it.

Based on observation, the facility failed to ensure smoke barriers were maintained to prevent the potential for smoke to spread in accordance with NFPA 101-2012, Section 19.3.7.3. These deficiencies affect the entire facility.

Findings include:

1. During an observation on 6/5/19 at 11:17 a.m., the 2-hour rated fire barrier doors separating the clinic from the CAH, were exercised. The doors failed to completely close and positively latch.

2. During an observation on 6/5/19 at 9:51 a.m., the fire doors' frame label was painted over and not legible on the door leading into the kitchen from the main hallway.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6. This deficiency affects all smoke compartments.

Findings include:

1. Review of facility documents regarding fire drills for the last year reflected there was no documentation for a completed drill for NOC shift during the second quarter of 2018.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). This deficiency affects all fire/smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 6/5/19 reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangements in the building and show inspections of all components of the doors in those barriers.

Based on observation, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d). This deficiency affects the entire facility.

Findings include:

1. During an observation on 6/5/19 at 10:12 a.m., the sterilization room was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

2. During an observation on 6/5/19 at 10:55 a.m., room 117 was inspected. The electrical panel in the room was blocked from easy access by various items being placed in front of it.

3. During an observation on 6/5/19 at 11:18 a.m., the CT scanning room was inspected. The electrical panel in the room was blocked from easy access by a large clothing receptacle.

4. During an observation on 6/5/19 at 11:25 a.m., the emergency room closet was inspected. The electrical panel in the room was blocked from easy access by various housekeeping items.

Based record review the facility failed to maintain the receptacles in patient areas. The deficient practice affected four (4) of four (4) smoke compartments, staff, and all residents. The facility had the capacity for 20 beds with a census of 3 on the day of survey.

The findings include:

Record review on 06/05/19 at 9:28 a.m. revealed non-hospital grade receptacles located in patient rooms throughout the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation, the facility failed to ensure that the oxygen storage locations were maintained in accordance with NFPA 99-2012 Edition, Sections 5.1.3.3.2 (10), 11.3.4.1 and 11.3.4.2.

Findings include:

1. During an observation on 6/5/19 at 9:31 a.m., the outside oxygen storage area was observed. Five K tanks and six A tanks were found to be unsecured, the chains used to secure the tanks was observed hanging on the fencing away from the oxygen tanks.

2. During an observation on 6/5/19 at 9:41 a.m., the outside oxygen storage area was observed. The oxygen storage area was located outdoors and lacked a cautionary oxygen sign. The sign must include the following wording as a minimum:
CAUTION:
OXIDIZING GAS(ES) STORED
NO SMOKING