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This deficiency is for Kingman Regional Medical Center (KRMC).

Based on observation, it was determined the facility failed to maintain a clear and unobstructed corridor. Blocked exits and unsecured equipment in the corridors could cause harm to the patients and staff in the event of an emergency if required emergency exits are blocked by equipment.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.2.3.4 "Any required aisle, corridor, or ramp shall not be less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met: (a) The fixed furniture is securely attached to the floor or to the wall. (b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830mm), except as permitted by 19.2.3.4(2). (c) The fixed furniture is located only on one side of the corridor. (d) The fixed furniture is grouped such that each grouping is not does not exceed an area of 50 ft* (4.6 m*). (e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by by a distance of at least 10 ft (3050 mm). (f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.

Findings include:

On March 7-8, 2018, the surveyor, accompanied by the Director of Plant Operations and Internal Audit Manager Quality Management, observed in the following areas that the corridors were not clear and unobstructed:

1. The emergency exit doors in the corridor between rooms 363 and 364 were blocked by the storage of two (2) wheelchairs and a clean linen rack;

2. North corridor Cathlab egress was blocked multiple lead apron racks;

3. The Central Supply corridor revealed the storage of surgery prep supplies, in that corridor.

During the exit conference on March 08, 2018, the above findings were again acknowledged by the Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director of Quality, Director of Plant Operations, and Audit Manager Quality Management.

This deficiency is for Kingman Regional Medical Facility (KRMC).

Based on observation, it was determined the facility failed to have a door closure on the door to self or automatic close and latch in a hazardous area. Failing to install self-closing hardware on a smoke/fire resistance door to a hazardous room could cause harm to patients in time of a fire if the door remained open.

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:

On March 08, 2018 the surveyor, accompanied by the Director of Plant Operations and Internal Audit Manager Quality Management, observed the following rooms did not have a door closure on the door to self close or automatic close and latch in a hazardous area:

1. Third floor Housekeeping room, across from room 366, door does not self-close.
2. Human Resource file room door does not self-close.
3. Dirty Utility room, in Cathlab Procedure area, door does not self -close.

During the exit conference on March 08, 2018, the above findings were again acknowledged by the Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director of Quality, Director of Plant Operations, and Audit Manager Quality Management.

This deficiency is for Hualapai Medical Center (HMC).

Based on record review and interview, it was determined the facility failed to have the fire sprinkler gauges replaced or recalibrated every five (5) years. Failing to inspect, test and maintain the sprinkler system could cause the system to be inoperable due to lack of maintenance during a fire and could cause harm to patients and staff.

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 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," Chapter 6, Section 6.3.4.1 states "Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge."

Findings include:

On March 06, 2018, the surveyor, accompanied by the Director of Plant Operations and Audit Manager Quality Management reviewed the annual sprinkler inspection and test report for HMC dated December 12, 2017. The facility has a total of seven (7) gauges for the sprinkler system. All seven (7) guages were past the required five (5) year replacement or recalibrating requirement per NFPA.

During the exit conference on March 08, 2018, the above findings were again acknowledged by the Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director of Quality, Director of Plant Operations, and Audit Manager Quality Management.

This deficiency is for Kingman Regional Medical Center (KRMC).

Based on observation, it was determined the facility failed to provide protective guards on light bulbs. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

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 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.

Findings include:

On March 08, 2018, the surveyor, accompanied by the Director of Plant Operations observed the following light bulbs exposed with no protective guards on the light bulbs:

1. Thirteen [13] unprotected light bulbs were in the BioMed room located in the basement.
2. Five [5] unprotected light bulbs were in the Electrical room, of the South Plant, located in the basement.
3. Fourteen [14] unprotected light bulbs were in the South Plant room located in the basement.

During the exit conference on March 08, 2018, the above findings were again acknowledged by the Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director of Quality, Director of Plant Operations, and Audit Manager Quality Management.

This deficiency is for Kingman Regional Medical Center (KRMC).

Based on observation, it was determined the facility failed to ensure that staff did not use daisy chain power strips.
The use of daisy chained power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

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.

Findings include:

On March 07, 2018, the surveyor, accompanied by the Director of Plant Operations and Internal Audit Manager Quality Management, observed the following strips in the facility, and not directly plugged in to the receptacle wall outlets.

Two [2] refrigerators were plugged into a power strip in the Dialysis Patient Treatment Station.

During the exit conference on March 08, 2018, the above findings were again acknowledged by the Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director of Quality, Director of Plant Operations, and Audit Manager Quality Management.

This deficiency is for Kingman Regional Medical Center (KRMC).

Based on observation, it was determined the facility failed to segregate empty and full oxygen E- type cylinders in a separate storage rack or stand. Failing to segregate compressed gas medical cylinders could cause harm to the patients if an empty bottle is pulled for use when a full bottle needed in a hurry for the 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 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

Findings include:

On March 07, 2018 the surveyor, accompanied by the Director of Plant Operations and Internal Audit Manager Quality Management observed four (4) full oxygen E-type cylinders being stored in the same storage rack as empty cylinders. There was no signage displayed to separate the two (2) racks.

During the exit conference on March 08, 2018, the above findings were again acknowledged by the Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director of Quality, Director of Plant Operations, and Audit Manager Quality Management.

This is a deficiency for Kingman Regional Medical Center (KRMC)

Based on record review and interview with staff, it was determined the facilty failed to have documented fire loss prevention in operating rooms. Failure to establish procedures for operating rooms emergencies and periodic evaluations made of hazards that could be encountered during surgical procedures, poses the high potential risk for patient injury or death.

NFPA 99 2012 Edition, Section 15.13 Fire Loss Prevention in Operating Rooms. Section 15.13.1.1 "An evaluation shall be made of hazards that could be encountered during surgical procedures." Section 15.13.1.2 "The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment." Section 15.13.3.8 "Health care organizations shall establish policies and procedures outlining safety precautions related to the use of flammable liquid or aerosol germicides or antiseptics used in anesthetizing locations, as required in 15.14.1, whenever the use of electrosurgery, cautery, or a laser is contemplated." Section 15.13.3.9.1 "Procedures for operating room/surgical suite emergencies shall be developed." Section 15.13.3.9.2 "Procedures shall include alarm actuation, evacuation, and equipment shutdown procedures and provisions for control of emergencies that could occur in the operating room, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department." Section 15.13.3.10.1 "New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use."

Findings include:

On March 06, 2018, the surveyor accompanied by the Director of Plant Operations and Audit Manager Quality Management reviewed the facility's policies and training records. No documentation was availabe to review while onsite during the survey pertaining to fire loss prevention in operating rooms.

During the exit conference on March 08, 2018, the above findings were again acknowledged by the Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director of Quality, Director of Plant Operations, and Audit Manager Quality Management.