The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

OSWEGO COMMUNITY HOSPITAL 800 BARKER DRIVE OSWEGO, KS 67356 July 20, 2016
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0910
Based on document review and Life Safety Code complaint investigation findings, the Critical Access Hospital (CAH) failed to meet the applicable provisions of the current Life Safety Code when they failed to maintain the fire alarm system since December 2015 potentially increasing the response time by emergency services in the event of an automatic alarm and the facility failed to conduct and properly document testing, inspection, and maintenance of the generator potentially resulting in the generator failing in the event of an emergency (refer to C-0231).

These deficiencies resulted in the Life Safety Code inspector of the state fire marshal's office notifying the facility's administration that the Centers for Medicare and Medicaid Services (CMS) identified these as Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient/resident) on July 19, 2016 at 11:30 am that were removed by exit on July 20, 2016 at 1:00 pm.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: C0930
Based on document review and LSC complaint inspection findings, the Critical Access Hospital (CAH) failed to maintain the fire alarm system as required by NFPA (National Fire Protection Agency) 72 potentially increasing the response time by emergency services due to having to call 911 in the event of an automatic alarm. The facility also failed to conduct and properly document testing, inspection, and maintenance of the generator in accordance with NFPA 99 and 110 resulting in the potential for the failure of the generator in the event of an emergency.


Findings include:


The facility had a capacity of twelve and a current census of four at the time of the state fire marshal's survey on 7/19/16.


<FIRE ALARM PANEL>


The state fire marshal's inspection on July 19, 2016 revealed the following findings regarding the fire alarm panel:


1. The facility had experienced problems with the fire alarm panel since December 2015.

2. The fire alarm panel was replaced on 7/5/16.

3. The facility lacked documentation of the false alarms or any fire watches between December 2015 and July 5, 2016.

4. On July 15, 2016, the new fire alarm panel experienced the same uninitiated alarm as before.

5. The facility lacked documentation that the new fire alarm panel was tested to ensure it was working properly.

6. On July 18, 2016, the contractor suggested the facility replace wiring to all of the devices.

7. At entrance conference on July 19, 2016, the facility's maintenance director was not sure the fire alarm was working as required.

8. The fire inspector on behalf of the Centers for Medicare and Medicaid Services (CMS) notified the facility's administration of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient/resident) Situation on July 19, 2016 at 11:30 am and the facility was placed in a fire watch until the fire alarm system had been tested and verification from the monitoring company received.
9. The contractor completed testing of the fire alarm and verification from the monitoring company the the alarm panel was back in service on July 19, 2016 at 5:00 pm.
10. The facility continued the fire watch after the fire alarm panel was back in service diue to an issue with the generator.


<GENERATOR>

The state fire marshal's inspection on July 19, 2016 revealed the following findings regarding the facility's generator:

1. On July 19, 2016 at 10:45 am, the generator failed to start when manually tested .
2. The facility lacked documentation of generator load testing prior to January 2016.
3. The generator annunciator panel (a group of lights used as a central indicator of status of equipment or systems in a building or other installation) lamps failed to illuminate when tested .
4. A switch that turns off the audible alarm signal from the panel was found in the off position. When the switch was turned on, no signal was heard to indicate trouble with the generator system.
5. The fire inspector on behalf of the Centers for Medicare and Medicaid Services (CMS) notified the facility's administration of an Immediate Jeopardy on July 19, 2016 at 11:30 am and the facility was placed in a fire watch until the generator system was functional.
6. On July 19, 2016 at 5:00pm, the contractor replaced the generator batteries. The generator was tested and ran with a successful load test.
7. On July 20, 2016, a contractor replaced bulbs and corroded wiring connections on the generator.
8. On July 20, 2016 at 1:00 pm, the generator was tested and communicated with the annunciator panel indicating the generator system was functional.
9. The facility removed the Immediate Jeopardy on 7/20/16 at 1:00 pm when the generator was back in service and so the facility was able to discontinue their fire watch.

Refer to the Life Safety Code complaint survey results dated 7/20/16 (ASPEN # RS1Y21) for additional details and NFPA references.