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Based on record review and interview the facility failed to ensure addressing their patient population within the facility emergency preparedness plan as required at CFR 482.15(a).

Findings:

Record review showed the facility emergency preparedness plan did not address or include the facility's patient/client population. The facility emergency preparedness plan did not contain strategies the facility would or will put in place to address the needs of at-risk or vulnerable patient populations it serves, or the services the facility would be able to provide during an emergency event.

On 02/11/20 at 2:30 pm the surveyor asked staff B to see where in the facility emergency preparedness plan the facility addressed the patient/client population they serve. Staff B and staff A stated they could not find where paitent population was addressed but will add it.

Based on observation and interview the facility failed to ensure doors in a required means of egress were not equipped with a latch or lock that requires the use of a tool or key from the egress side as required.

Findings:

On 02/12/20 at 2:41 pm deadbolt lock with a thumb turn latch was observed on the nuclear medicine door.

On 02/12/20 at 2:41 pm staff C was asked why there was a two action latch on the corridor access door and they stated it had been added for security. Staff C stated they would remove the thumb turn latch deadbolt to be in compliance.

On 02/12/20 at 3:09 pm a keyed deadbolt which would require two actions to open was observed to be installed on a sliding door bwtween the kitchen and dinning room area.

On 02/12/20 at 3:09 pm Staff C was asked if all staff have a key for this keyed deadbolt. Staff C stated not all staff have a key to the keyed deadbolt on the egress door.

Based on observation and interview the facility failed to ensure ten of eleven exit discharges had emergency generator powered or battery powered backed-up emergency lighting installed as required.

Findings:

On 02/12/20 at 1:20 pm the surveyor walked to each of the eleven exit discharges the facility had and ten of the eleven designated exit discharges were observed to not have emergency powered lighting as required.

On 02/12/20 at 1:45 pm the surveyor asked staff C if each of the eleven exit discharge lights were on the emergency generator. Staff C stated they are not on the emergency generator. The surveyor asked staff C if the exit discharge lights each have battery backed up emergency lighting. Staff C stated no they are not on battery backed up emergency lighting. Staff C stated only one of the exit discharges has emergency lighting as required because DNV found one on their survey. The surveyor walked to each of the eleven exit discharges and found ten of the eleven to not have the required emergency lighting that is required.

Based on record review and interview the facility failed to ensure ventilation within the facility were in accordance with ASHRAE 170-2008 ventilatory standards as required.

Findings:

Record review showed the facility's annual test and balance inspection reports for 2017 and 2018 were not completed.

Record review showed the endoscopic procedure area medical staff were not maintaining documention or checking temperature or relative humidity readings in endoscopic rooms one or two before any scheduled endoscopic procedures to ensure temperature or relative humidity levels were in compliance as required per ASHRAE 170-2008 ventilatory standards.

On 02/12/20 at 1:56 pm staff C was asked for the annual test and balance inspection reports for the last three years 2019, 2018 and 2017. The surveyor only received the 2019 test and balance inspection report. The surveyor asked Staff C why the other two years were not completed. Staff C stated the test and balance vendor had been in multiple times but had only repaired roof top HVAC units and not completed annual inspections.

On 02/13/20 at 3:30 pm the surveyor asked Staff C if the medical staff that work in the endoscopic rooms were also checking and documenting temperature/relative humidity before scheduled endoscopic procedures to ensure compliance with ASHRAE 170-2008 ventilatory standards. Staff C stated no. Staff C stated he does check the temperature and relative humidity but the times/days that are checked are not scheduled to coincide when endoscopic cases are scheduled to be performed in the endoscopic area.

Based on record review and interview, the facility failed to ensure fire drills conducted included the transmission of a fire alarm signal as required in NFPA 101, 2012 Edition, Chapter 19.7.1.4 through 19.7.1.7.

Findings:

Record review of the facility's fire drill documentation showed each fire drill did not include verification of a transmission of a fire alarm signal.

On 02/12/20 at 10:25 am staff C was asked to show the surveyor were they document how they verify the transmission of a fire alarm signal. Staff C stated they did not document it on the fire drill report forms but will add it.

Based on record review and interview the facility failed to ensure any means of egress in any area undergoing improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency and compliance with NFPA 241.

Findings:

Record review showed an ILSM during the dates of 09/12/17 to 11/01/17 where the flooring in an egress access flooring area (endoscopic procedure rooms) was being replaced and no daily inspection log documentation was completed.

On 02/11/20 at 1:37 pm the survyeor asked Staff C if there has been any Interm Life Safety Measures (ILSM) within the last three years. Staff C stated yes and provided the documentation. The surveyor asked Staff C where the daily log of inspection for the area for when the new flooring in the endoscopic area was being replaced. Staff C stated they did not see the area as being part of the egress area do they did not do it. The surveyor explained any rooms within a health care occupancy is surveyed as an egress pathway.

Based on record review and interview the facility failed to ensure the building system risk assessments for the facility (EES) essential electrical system and medical gas system was completed as required.

Findings:

Record review showed the building systems risk assessments for the facility essential electrical risk assessments and medical gas system was not completed for 2019, 2018, or 2017. The building systems risk assessment does not exist.

On 02/12/20 at 10:42 am the surveyor asked the staff B and C for the building systems risk assessments for EES and the facility medical gas system. Staff B stated he thought they had it but later produced a document that once reviewed by the surveyor did not have the categories outlined per Chapter 4 of NFPA 99, and did not have any rooms identified or listed. Staff B stated they would develop the building systems risk assessment for EES and medical gas as required.