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.

ST JOHN MEDICAL CENTER, INC 1923 SOUTH UTICA AVENUE TULSA, OK 74104 July 18, 2012
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the clinical record documentation adequately reflected the care and services provided to the patients. Findings:

A hospital policy, titled, "Medical Record Entries", documented, "... Each clinical encounter will be documented as soon as possible after its occurrence..."

A hospital policy, titled, "Cerner Downtime", documented, "... Documentation... Downtime [greater than] two hours: Utilize downtime packets. Paper forms should be placed in the charts... Utilize the interdisciplinary progress note to document any other patient care, notifications or events as a narrative note..."

On 06/30/12, the hospital experienced a catastrophic power failure when the hospital generators did not engage to provide emergency power to critical areas. The hospital had no electrical power for approximately 45 minutes - from 8:40 a.m. until 9:25 a.m.. During this time, all electrical equipment failed including ventilators, monitors and infant warmers. Oxygen and medical gas supply was also disrupted when the air compressors for these systems failed.

As a result of the power failure, the hospital electronic medical record documentation program, Cerner, was not fully operational for several hours.

On 07/10/12, 07/16/12 and 07/17/12 clinical records were reviewed for patients in the emergency department, all intensive care units, surgery department and labor and delivery at the time of the power failure.

1. Patient 11 was admitted on [DATE] to the labor and delivery department. The patient was treated with IV fluids and pain medication. A decision was made to transfer the patient to another hospital when the power outage made C-section services unavailable.

The electronic medical record did not contain nurses' notes, physician's orders or a record of the transfer. There was no documentation of care provided during the power outage.

Staff J stated there may be paper documents that have not been scanned into the electronic record. Those records were not provided to the surveyors.

2. The hospital identified eight NICU patients (#12, 13, 14, 15, 16, 17, 18 and #19) who were on ventilators, cardiac / respiratory / temperature monitoring and infant warmers at the time of the power failure.

Staff A stated when the power failed, the nursing and respiratory staff had to manually ventilate patients and use battery powered monitors. She stated there were not enough battery powered monitors for all patients who needed them, so staff had to prioritize what patients were placed on them.

Of the eight records reviewed, only one record, (#17) documented the alternate interventions (such as manual ventilation, the use of RAM cannulas and high flow, non-humidified oxygen) and care provided to the infant when the ventilator, oxygen, monitor and warmer failed.

The other seven NICU records had no nurse's notes during the time of the power outage. There was no information about equipment failure, manual ventilation, who ventilated the patients, how long they were manually ventilated, how the infants were monitored and kept warm, or other care provided during the disaster.

3. Records were reviewed for seven patients (#31-37) who were cared for in the cardiovascular intensive care unit at the time of the power outage.

Patient #31 and #35 had documentation of the power outage and alternate interventions put in place when equipment and oxygen failed. None of the other patients had documentation for periods of two hours or longer during the power outage. There was no documentation of manual ventilation by staff, although numerous staff who were interviewed stated there were at least three in this unit who were manually ventilated.

4. The clinical records for the patients in surgery (#1, 2 and #6) at the time of the power failure had no documentation of the event and no documentation of alternative nursing care/interventions given during that period.

5. Clinical records were reviewed for three adult ICU patients identified by staff L as being manually ventilated when the power outage occurred. There was no documentation of this or of any care provided during the power outage and up to three hours afterward.

On 07/17/12 at 10:20 a.m., staff L was asked if documentation should have been done by the respiratory therapy and/or nursing staff to indicate ventilators and oxygen delivery failed and the patients had to be manually ventilated and placed on portable oxygen tanks. He stated they should have.

Staff D stated documentation should have occurred on paper while the electronic record was down, or documentation should have been done in the electronic record retrospectively.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the clinical record documentation adequately reflected the care and services provided to the patients. Findings:

A hospital policy, titled, "Medical Record Entries", documented, "... Each clinical encounter will be documented as soon as possible after its occurrence..."

A hospital policy, titled, "Cerner Downtime", documented, "... Documentation... Downtime [greater than] two hours: Utilize downtime packets. Paper forms should be placed in the charts... Utilize the interdisciplinary progress note to document any other patient care, notifications or events as a narrative note..."

On 06/30/12, the hospital experienced a catastrophic power failure when the hospital generators did not engage to provide emergency power to critical areas. The hospital had no electrical power for approximately 45 minutes - from 8:40 a.m. until 9:25 a.m.. During this time, all electrical equipment failed including ventilators, monitors and infant warmers. Oxygen and medical gas supply was also disrupted when the air compressors for these systems failed.

As a result of the power failure, the hospital electronic medical record documentation program, Cerner, was not fully operational for several hours.

On 07/10/12, 07/16/12 and 07/17/12 clinical records were reviewed for patients in the emergency department, all intensive care units, surgery department and labor and delivery at the time of the power failure.

1. Patient 11 was admitted on [DATE] to the labor and delivery department. The patient was treated with IV fluids and pain medication. A decision was made to transfer the patient to another hospital when the power outage made C-section services unavailable.

The electronic medical record did not contain nurses' notes, physician's orders or a record of the transfer. There was no documentation of care provided during the power outage.

Staff J stated there may be paper documents that have not been scanned into the electronic record. Those records were not provided to the surveyors.

2. The hospital identified eight NICU patients (#12, 13, 14, 15, 16, 17, 18 and #19) who were on ventilators, cardiac / respiratory / temperature monitoring and infant warmers at the time of the power failure.

Staff A stated when the power failed, the nursing and respiratory staff had to manually ventilate patients and use battery powered monitors. She stated there were not enough battery powered monitors for all patients who needed them, so staff had to prioritize what patients were placed on them.

Of the eight records reviewed, only one record, (#17) documented the alternate interventions (such as manual ventilation, the use of RAM cannulas and high flow, non-humidified oxygen) and care provided to the infant when the ventilator, oxygen, monitor and warmer failed.

The other seven NICU records had no nurse's notes during the time of the power outage. There was no information about equipment failure, manual ventilation, who ventilated the patients, how long they were manually ventilated, how the infants were monitored and kept warm, or other care provided during the disaster.

3. Records were reviewed for seven patients (#31-37) who were cared for in the cardiovascular intensive care unit at the time of the power outage.

Patient #31 and #35 had documentation of the power outage and alternate interventions put in place when equipment and oxygen failed. None of the other patients had documentation for periods of two hours or longer during the power outage. There was no documentation of manual ventilation by staff, although numerous staff who were interviewed stated there were at least three in this unit who were manually ventilated.

4. The clinical records for the patients in surgery (#1, 2 and #6) at the time of the power failure had no documentation of the event and no documentation of alternative nursing care/interventions given during that period.

5. Clinical records were reviewed for three adult ICU patients identified by staff L as being manually ventilated when the power outage occurred. There was no documentation of this or of any care provided during the power outage and up to three hours afterward.

On 07/17/12 at 10:20 a.m., staff L was asked if documentation should have been done by the respiratory therapy and/or nursing staff to indicate ventilators and oxygen delivery failed and the patients had to be manually ventilated and placed on portable oxygen tanks. He stated they should have.

Staff D stated documentation should have occurred on paper while the electronic record was down, or documentation should have been done in the electronic record retrospectively.

Staff D was asked if there was sufficient documentation to determine if a negative outcome had occurred for any patient affected by the power outage. No response was given.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to maintain facilities to ensure the safety of the patients. Findings:

1. The hospital experienced two Code Yellow (disaster) events involving power outages in the year prior to June 30, 2012. Areas of concern were documented by the hospital at the time of the last event in March 2012 that included: inadequate emergency lighting in some areas, inadequate numbers of flashlights, back-up battery problems and widespread communications problems. Also identified was a lack of emergency power in the cath lab and problems with certain lab equipment that required room air temperatures to be controlled in order for the machine to work.

2. There was no documentation of action taken by the hospital in response to the areas of concern identified from the two other power outages prior to June 30, 2012.

3. When the catastrophic power failure occurred on June 30, 2012, the hospital took generator #3 out of service and determined the other four generators were operational. The hospital had not completed consultation with the generator and circuit breaker engineers for a root cause analysis of the problem as of July 17, 2012. During this time, the hospital continued to operate as usual.

4. The hospital discovered one of two electrical feeds that powered the hospital had been taken out of service. The power company did not notify the hospital it was powered by one feed. After the single power feed failed, there was no documentation the hospital consulted with the local power company as to why one electrical feed was taken off line and the other failed. There was no evidence the hospital was working with power company, local officials and/or others to ensure the hospital was notified before, or at the time of, potential power problems.

5. At the time of the survey, the hospital had not taken action to comprehensively analyze the catastrophic generator power failure of June 30, 2012 and its impact on each hospital department, all the main campus care areas and its health system facilities in outlying areas. Several departments had not responded to a request for a written critique of the event. One hospital document had limited analysis of the event, but was not comprehensive for the entire medical complex and all its outlying services.

6. There was evidence a meeting was held to discuss the June 2012 disaster. Hand written notes were documented, but did not record the date and time the meeting was held, and there was no documentation of who attended the meeting. At this meeting, some immediate corrective actions were suggested and documented.

7. There was no documentation medical staff were involved in debriefing/critiquing/analysis/planning after the disaster. There was no documentation the QA/PI committee was activated in response to the disaster.

8. There was no documentation of corrective actions already taken in response to the event. The surveyors requested this documentation on multiple occasions from multiple persons.

9. There was no documentation of the development of comprehensive formal action plans, time tables and persons responsible for those corrective actions suggested.

10. No policies and procedures had been revised in response to the event. The disaster policy had not yet been revised to address a total power failure within the facility. There was no documentation of work in progress.

11. Even though some changes in protocols and procedures had occurred as a result of the disaster, no staff training had been conducted.

12. There was no evidence the hospital continued to monitor/diagnose/resolve residual effects on vital systems, primarily the information technology systems. This was determined when documentation indicated the hospital again went on a divert status on the night of 07/02/12 due to continuing computer problems. Documentation indicated " server problems " had significantly affected the hospital " four or five times " since the initial power failure.


See also Tags 0701, 0702, and 0724 and Life Safety survey.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on record review and interviews with hospital staff the hospital does not ensure that a comprehensive plan to ensure the safety and well being of patients during emergency situations. The facility experienced three power failures within one year. Pertinent information collected after each power failure was not utilized to revise, train, and implement improved disaster plans to ensure the safety and well being of all patients.

Findings:

According to the policy "Disaster Plan approved November 11, 2010; St. John Medical Center has adopted the Hospital Incident Command System (HICS) version IV standard as the All-Hazards command structure within our organization that directly links with our communities' command structures. As part of an effective HICS plan, an evaluation of disasters, (man-made and natural) is conducted with respect to probability, severity and facility preparedness. This evaluation is in the form of a Hazard Vulnerability Analysis (HVA). Appropriate emergency response plans are developed based on the results of this analysis." Further- B. Activation and Notification 1. Implementation "Once determined that the Disaster Plan is to be activated, the ranking person outlined above will assume the role of Incident Commander, and activate the Incident Command Center. Notification to staff is crucial;the Incident Commander will call the PBX operator and instruct that a Code Yellow (Internal or External) Phase 1 to be announced overhead. Staff will be updated as necessary.. 2. Notification of Key Personnel Department Directors/Managers: ....Upon learning of an internal or external disaster or incident, the directors/managers are expected to respond to the facility and report directly to their departments." The policy also stipulates "Internal backup communications: Two way radios will be passed out to all pertinent areas.....a master list of phone numbers shall be compiled and distributed to all pertinent areas....The PA system will be used as needed to deliver information or contact individuals within the hospital." The policy also stipulates in "Department and Responsibilities" Surgery; all non emergent procedures will be prevented from starting . Those in progress will expedite if practical."

The policy further stipulates- F. Recovery 1. Once the disaster is declared over, an assessment will be made to determine if the facility can safely resume medical care services and provide a safe environment for patients, staff and visitors. The following activities will be included as appropriate in making the decision to resume normal operations: d) Ensure employee support programs have been instituted, i.e. crisis counseling, flexible work hours, day care, particularly if the staff and hospital have been directly impacted; f)restore internal and external communication devices; g) Inventory equipment and supplies for damage and determine if additional supplies need to be obtained for insurance purposes. Damaged supplies and equipment will be retained in a safe non patient area until approval is received from the insurance agent for disposal; k) Ensure records and data have been protected and restore information utilizing SunGard Availability Services, if needed. l)Keep detailed time-lined records of all recovery steps. G Exercise Critique 1. A designated individual will monitor performance and document opportunities for improvement during emergency response exercise.

1. Surveyors reviewed facility documents indicating a power failure had occurred at the facility June 30, 2012 and the emergency generators failed to engage and restore power to critical areas. The hospital was without electrical power for approximately one hour. Documents provided to surveyors at the time of the survey (07/10/12) indicated regular power from the substation was restored prior to generator power failure correction.

The impact on direct patient care is as follows: some life support equipment (ventilators, BI-PAP, and c-pap) and cardiac/respiratory monitoring equipment had battery back-up capabilities, others did not. None of the batteries lasted for the duration of the power outage. Nine adult intensive care unit (ICU) patients required manual ventilation (bagging) when back up batteries failed. Staff L told surveyors as many as 18 patients throughout the hospital were manually ventilated during the power outage. He was asked if he was aware CNAs were bagging patients. He stated he was not aware of that. He was asked if CNAs were trained to do that procedure. He stated he didn't know.

Staff L was asked if all of the hospital's ventilators had external battery back-up. He stated they all had the capability, but were not all equipped with back-up batteries. He stated there were some back-up batteries in storage that were not utilized on ventilators. He was asked why the back-up batteries failed with in 10-15 minutes as documented by staff. He stated it could be the ventilators were not plugged into a power source while they were stored.

He was asked what the hospital had done in response to these issues. He stated they were considering purchasing long-life (2-4 hour capability) back-up batteries for all ventilators. He stated he had instructed his staff to ensure all ventilators were plugged in when not in use. He stated he sent an e-mail to his staff regarding this. He provided an e-mail dated 07/16/12 (17 days after the catastrophic power failure) that documented those instructions to staff. He was asked if nursing staff had been instructed on keeping ventilators plugged in as well. He stated they had not.

He was asked if there had been a policy and procedure generated or revised to address keeping ventilators plugged in when not in use. He stated this was not necessary because this was considered "guidance" information only, and not a policy/procedure.

One ICU patient who was on a BI-PAP machine that failed when the power went out (the BI-PAP machines had no battery back-up) was prepped for emergency intubation. However, right before the intubation the utility power was restored and the BI-PAP machine resumed operation. Staff L was asked what the hospital had done in response to the failure of the BI-PAP machines during the power outage. He stated they were looking into BI-PAP machines with back-up batteries.

Six neonatal intensive care unit (NICU) patients requiring N-CPAP had to be placed on high flow nasal cannula oxygen without humidity. One intubated NICU patient was manually ventilated due to power/battery loss of ventilator support.

At the time of the survey, the hospital had made no provision for a catastrophic failure of BI-PAP and N-CPAP machines.

Nursing and medical staff triaged which critical patients were placed on the available battery supported cardiac monitors. Some of the ICU and NICU patients were monitored with stethoscopes and axillary thermometers as there were no portable monitors available. Some portable monitors were locked in a store room that became inaccessible when the power failed. All telemetry systems failed.

At the time of the survey, the hospital had made no assessment, recommendations or plans regarding a possible need for more battery-powered monitors, policies and procedures for failure of telemetry or immediate resolution for correction of doors defaulting to a locked position in the event of power failure or other IT system failure.

Three patients were in the surgical suite when the power failed. One patient's surgery was completed using flashlight illumination. Another patient's surgery could not be continued and the surgical wound was packed with saline/antibiotic soaked sponges until the power was restored and the surgery could resume. The third patient was maintained under anesthesia (the surgery had not started) until the power came back on.

There was no documentation in the June 30, 2012 disaster binder that documented the incident commander formally suspended surgeries and all other elective (non-emergent) procedures until safe to resume. There was no documentation of dates/times of critical events and actions.

Patients requiring frequent blood sugar monitoring and/or on insulin drips did not receive blood sugar monitoring for two hours or more when the point of care glucometers failed. The laboratory could not test blood glucose levels because their UPS did not function.

At the time of the survey, the hospital had made no assessment or recommendations for catastrophic failure of the point of care system and the shut down of the laboratory. There was no evidence policies and procedures were developed to address this scenario.

Patients receiving dialysis were taken off dialyzers and their blood was returned manually. A patient arrived to the emergency room via ambulance in full arrest. Resuscitation efforts continued in the atrium of the emergency room to utilize natural light.

At the time of the survey, there was no documentation the hospital had critiqued the response of the dialysis services during the power failure. There was no documentation the hospital had analyzed the need to resuscitate patients outside the ED because there was not enough light inside the department. There was no documentation of the ED response to the disaster.

Staff who were present at the time of the total power failure told the surveyors there was no emergency lighting anywhere in the hospital. Some staff relied on their personal cell phones and utilized a cell phone "flashlight application" for illumination. There was no emergency lighting in the stairwells or inner areas of the hospital. Patients in areas without windows were in complete darkness. Staff reported there were not enough flashlights or headlights available for use.

At the time of the survey, the hospital was asked to provide documentation that verified what additional equipment had been purchased in response to this need. None was provided.

The uninterruptable power source (UPS) serving the computer systems failed. Several computer issues were documented during the total power outage and throughout the day. Technology problems persisted over several days after the power failure. Staff M stated the hospital had two UPS systems to support IT services. One UPS failed within minutes of the total power failure and the other UPS never worked. He was asked what the hospital had done in response to the problem. He stated they were looking into it.

The facility reported to MERC they needed their emergency room to be on divert due to computer issues. The hospital's emergency room was on divert for over six hours the day of the disaster. Another local hospital was on generator power due to the sub station malfunction and was also on divert. Communication between the hospital and the MERC system indicated the lengthy divert status created a situation whereby the other local hospital receiving emergency patients eventually went to a divert status when their resources were depleted. The staff reported there were problems communicating with other hospitals and healthcare entities. Each hospital on divert was unknowingly sending drive-up patients to hospitals also on divert.

At the time of the survey, there was not documentation of an action plan to address this problem.

The hospital's mobile paging system was down. Several managers/directors reported delayed or no notification of the disaster situation. Managers were notified of the disaster by frontline staff working during the disaster. The PBX operator had no computer capabilities and could only communicate through land line telephones. Some emergency call lists were not updated and had incorrect phone numbers.

Documentation of events during the disaster indicated the facility could receive incoming telephone calls but was not able to call out. Radio communication was lost to other St. John Health Center campuses. Some of the batteries on the hand-held radios failed.

At the time of the survey, there was not documentation of an action plan to address these communication problems.

The hospital's overhead paging system and public address system was down. Staff present during the disaster indicated there were no updates and very limited communication regarding the status of the code yellow and updates on vital facility systems. There was no documentation of an action plan to address this in the event of a total power failure.

Staff did not have access to policies and procedures (such as the diaster plan and downtime procedures) as hospital policies are computerized and the system was unavailable. The hospital staff reported they were going to print hard copies of these critical procedures, but there was no documentation to support this had been done, or that hospital staff were notified and trained on this change.

Electronic medical records were inaccessible during the power outage and for several hours after the power returned. Medication administration records, lab, and radiology reports could not be accessed. Downtime documents were not available to all staff. Staff were not directed to implement downtime clinical documentation procedures. These outages affected the other St. John campuses and impacted patient care in those facilities.

The downtime read-only emergency back-up medical record was not available when the computers for this lost battery power. There was no documentation of the hospital's response and plan to correct these issues.

Hospital documentation indicated the badge reader system on doors failed in a "locked" position which prevented access to multiple areas of the hospital and temporarily trapping staff in some areas. This failure also prevented access to battery back up clinical equipment (which could have been used during the disaster), disaster "bags", and medication rooms.

Pharmacists could not leave the pharmacy to open the automated medication dispensing machines (PYXIS) with a key. A physician opened a PYXIS machine with a screwdriver to obtain emergency medications. Information from the PYXIS machines including available medication inventory, patient medication profiles and medication error prevention systems were not available.

There was no documentation the hospital assessed the total impact of the down Pyxis/McKesson systems on patient care and the staff. There was no documentation of the impact of the failure of the Cerner system with the failures in laboratory, pharmacy, radiology and other systems.

2. According to hospital documents, the hospital experienced two other power outages that were declared disasters prior to June 30, 2012. Some of the issues identified on June 30, 2012 had been identified during the previous disasters. For example, when the surveyors reviewed documentation of the two disaster events of July 2011 and March 2012, it was found that both events were actual power outages involving the same power substation. In both events, the hospital emergency generators engaged and provided power to the facility. However, there was no documentation the hospital had investigated the power substation problems.

During both previous power outage events, documentation provided to surveyors indicated several key personnel did not receive pages regarding the disaster. The radiology systems did not function for the facility or outlying facilities. Staff reported there was not enough light in multiple areas of the hospital. Communication devices did not work. Critical devices in the cardiac catherization area did not function. Contact with the power company could not be made as the phone number to the power company indicated it had been disconnected . There was no evidence the facility utilized these previous disasters to develop a comprehensive plan to improve facility functioning during power outages and other disaster events.

A hospital document, titled, "Hospital Exercises - Disaster Events Emergency Management Critique" documented issues identified from the June 30, 2012 catastrophic power failure, including:

" Command Center: Need longer phone cords for disaster phones. It took 89 operator long time to answer calls. Code Yellow could not be sent.

Safety and Security: Some card readers not working. Med rooms had to be manually unlocked. Limited radio communication. Access control system somewhat ineffective.

Logistics: No radiology, tube system, call lights, computers, lab, paging, Pyxis. The glucometers on floors did not work. Need for portable ones on each floor. Menus had to be manually completed by dietary.

Planning: Computer network failed, Cerner, McKesson, Star, Lawson, Cloverleaf interface. All had to be manually restarted.

Staffing: Transport staff was sent to be runners to deliver the tubes. Security staff unlocked doors and manned elevators.

Operations: Surgeries cancelled. ED closed. No ventilators working for patients until power restored. Unable to do laboratory testing (analyzers). Dialysis patients taken off machines. Cath lab not functioning.

Utilities Management: Most of the phone system did continue to function. Only IP phones did not work.

Recommendations for Improvement:

Incident Command Center: ICC staff tripping over phone cords - acquire longer cables.

Med rooms: fault to unlock

Limited Communication by Security: (no documented response)

Access Control System somewhat ineffective: (no documented response)

Systems not working: Radiology, tube system, call lights, computers, paging, Pyxis, caremobiles (hand held bar code readers): (no documented response)

Glucometers did not work: Need to implement an approved back-up system to the glucometers when power and network applications are lost for an extended period of time.

IT Emergency back-up UPS did not function: (no documented response)

Emergency Power: Back up generators did not work: (no documented response)"

The surveyors requested documentation of all work products, (from all departments) related to the event including meeting minutes, action plans, staff training records, product/equipment purchase records, and policy and procedure revisions. The hospital did not provide any of this documentation.
VIOLATION: EMERGENCY POWER AND LIGHTING Tag No: A0702
Based on record review and staff interview, it was determined the hospital failed to ensure there was emergency power and lighting in the operating, recovery, intensive care and emergency room s.

On June 30, 2012, hospital records documented a catastrophic power failure occurred when a local utility substation lost electrical power. As a result, the hospital lost electrical power and the five emergency generators failed to engage to restore emergency power to critical areas.

The hospital was without electrical power for approximately 45 minutes.

On July 10, 2012, staff F stated during the power outage, there was no emergency lighting and no emergency power to critical areas.
VIOLATION: LOCATION OF FACILITIES Tag No: A0723
Based on observation of Computed Tomography(CT) Rooms 1, 2, 3 Chapman Building, Endoscopy /APC (Ambulatory Procedure Clinic) Rooms Seidfried Building ,Magnetic Resonance Imaging (MRI) Suites (Heyman Building) and interviews with staff the facility failed to provide Diagnostic and therapeutic facilities in rooms or areas specifically designed for the purpose intended.

Findings:

1. During a tour of the facility on July 16, 2012 surveyors were told by the MRI Director the facility has been providing anesthesia for patients who could not tolerate intravenous sedation, who were claustrophobic, mentally challenged, or who had head trauma. Surveyors observed a special Anesthesia Machine that will tolerate MRI environment. During the course of the tour the surveyor asked a staff member of the MRI Unit if she could turn off the medical gas off in case of a fire. She did not know but was instructed where they were during this survey, she stated " I have been walking by those for five years and did not know what they were for " .
2. During the tour the Endoscopy/ APC Director told surveyors anesthesia was provided in the suite as well as 701.
3. During the tour surveyors were also told CT rooms 1,2, and 3 were used as anesthetizing locations.
4. The facility failed to monitor and insure that humidity levels in anesthetizing locations in the CT,MRI, and Endoscopy/APC rooms were at 35% or greater NFPA 99 1999 edition chapter 5-4.1.1. This finding was verified with Staff Fon July 16, 2012 at 11:30.
5. The facility failed to provide MRI, CT, Endoscope/APC rooms with ventilating systems that will exhaust products of combustion NFPA 99 1999 edition chapter 5-4.1.2, This finding was verified with Staff Fon July 16, 2012 at 11:30.
6. The facility failed to provide MRI, CT, and Endoscope/APC, the electrical supply of the ventilating equipment with emergency power 5-4.1.3. This finding was verified with staff F on July 16, 2012 at 11:30.
7. The facility failed to provide MRI, CT, and Endoscope/APC , failed to provide Medical Gas Shutoff valves located outside vital life support areas (anesthetizing locations) NFPA 99 4-3.1.2.3 (m) (8). This finding was verified with Staff F on July 16, 2012 at 11:30.
8. The Governing Body failed to provide designated Anesthetizing Locations in accordance with NFPA 99 1999 edition chapter 12-2.7. This finding was verified with staff B on July 16, 2012.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on review of hospital documents, interviews with staff, policy and procedure the facility failed to ensure facility and medical equipment are identified, maintained, and supplied during emergency situations.

Findings:

1. Disaster events (#3) the emergency generator failed to engage and the facility was without regular or emergency for approximately one hour. According to documents received at the Department generator parts were ordered as a result of the generator manufacturers inspection. . July 10, 2012 surveyors interviewed Staff F regarding the generator failure. Staff F told surveyors at the time of the failure he was not present in the facility but was speaking with staff throughout the disaster. Staff F indicated regular utility power returned before the emergency generators functioned. According to Staff F the facility maintained five emergency generators each with a breaker. During the disaster event generator/breaker set
#3 malfunctioned which caused the rest of the generators/breaker (1,2,4,5) to shut down on a protective relay fault. Documents received at the Department indicate that a technician from the generator company arrived later that day (June 30, 2012) and noticed the breaker for genset (generator) 3 was closed when it should have been open. The indicator light on the front of the gear showed the breaker to be open. The protective relay showed the breaker to be closed thereby causing the shut down on a protective relay fault. There was no documentation the breaker manufacturer had been to the facility to determine the cause of the malfunction. As of July 10, 2012 none of the remaining breakers had been inspected and tested by the manufacturer. Staff F told surveyors the breaker manufacturer had been contacted and representatives were supposed to be at the facility within a week or so.

As of July 17, 2012 the facility could not provide documentation as to the cause of the malfunction in the breaker. There was no documentation the electrical utility company had provided the facility information as to the cause of the power failure, the lack of an automatic transfer switch, and multiple power surge problems. There was no documentation the facility had communicated with the electrical utility company regarding these issues. There is no documentation the facility has reviewed the events and developed/implemented plans to reduce the potential for electrical system failures. There is no documentation a plan is in place should a catastrophic generator failure occur again.

2. On July 17, 2012 surveyors reviewed documents from three disaster events, July 2011(Event #1), March 2012 (Event #2), and June 2012 (Event #3). All disaster events related to power outages. Two (#1,#2) of the three events the emergency generator engaged and supplied the facility with power. One of the events (#3) the emergency generator failed to engage and the facility did not have power for approximately one hour. Documents at the facility stipulate during events #1 and #2 staff reported the following: Several key personnel did not receive official notification of the disaster event; radiology lost reading capabilities (PAX) system to the main hospital and to outlying related hospitals; not enough lighting in multiple locations; lack of flashlights and batteries; lack of communication during the events; difficulties with different components of the information technology software; lack of information to and from the power company; disaster call lists (including the power company contained multiple wrong numbers; and cardiovascular lab not on emergency power. There was no documentation the facility had contacted the utility company to determine what could be done to improve electric service to decrease the likelihood of power interruption in the future the facility.
Documentation after event #3 in which the facility suffered a catastrophic loss of power stipulates similar more severe problems. See tag 701.

2. During the time of event #3 the facility had no internal lighting. Staff told surveyors clinicians used flashlight applications on cell phones to work. Staff also stated there were not enough flashlights and batteries and clinicians went to a nearby store and purchased more. Nursing staff told surveyors they purchased glow sticks at a local store to give the patients for some illumination. Documentation from events #1 and #2 indicate lack of lighting and battery powered light sources were also a problem during those events. There is no documentation the facility made adequate provisions for items found to be inadequately supplied in Events
#1 and #2 prior to the catastrophic power failure Event #3.

3. Documentation of the event stipulates communication systems failed. Staff were not notified of the disaster through official channels. Some staff did not get notified of the disaster. Documentation stipulates there was limited communication regarding the disaster and the restoration of power. These communication failures were reported in disaster documentation for Events #1 and #2. There was no documentation or action plan developed and implemented to improve the functioning of the communication systems prior to the catastrophic June 30, 2012 failure. There is no documentation the facility has reviewed the events and developed/implemented plans to reduce the potential for system failures. See tag 701

4. Multiple components of the information technology system failed and continued to fail for several days after Event #3. These failures prompted the hospital to contact MERC and have emergency room services placed on divert. These failures also impacted multiple facility related entities resulting in MERC being notified of the need for a sister facility to be placed on divert. Documents between the MERC commander and the hospital indicate problems continued to occur up to at least July 2, 2012. These information technology failures were reported in disaster documentation for Events #1 and #2. There is no documentation or action plan developed and implemented after Events#1 and #2 in which the facility implemented an improved information technology plan prior to the catastrophic event #3. There is no documentation the facility has reviewed the events and developed/implemented plans to reduce the potential for system failures since the catastrophic event #3. . See tag 701