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Based on record review and interview, the hospital failed to ensure development, maintenance, and annual review of a facility-based community-based risk assessment using an all hazards approach as required.

Findings:

Record review of the emergency preparedness plan dated 04/21/14 showed the facility did not review the facility-based and community-based risk assessments annually that utilized an all hazards approach. An annually updated emergency preparedness plan document did not exist for 2015, 2016, 2017.


On 01/09/18 at 11:17 am, the surveyor asked the facility administrator to see the written documentation of the facility's risk assessments and associated emergency preparedness strategies. The facility administrator stated the risk assessment had not been updated annually since 04/21/14.

Based on record review, observation, and interview the facility failed to ensure staff were trained on the procedures for the facility tracking system of staff and patients.

Findings:

Record review of three of three facility training records for emergency preparedness did not show verification the facility staff received training on the patient tracking system procedures used by the facility. The staff training documentation did not exist.

On 01/09/18 at 2:53 pm three nursing facility staff (nurse staff #1, nurse staff #2, nurse staff #3) were asked about the facility's tracking system. Nurse staff #1 and nurse staff #3 were unable to describe and demonstrate the patient tracking system used by the facility of staff and patients.

Nurse staff #2 stated she was familiar with the tracking system, but she did not receive the training with the facility. Nurse staff #1, nurse staff #2, and nurse staff #3 stated they had not received any training through the facility and were unaware of the facility's patient tracking system procedures.

Based on record review and interview, the facility failed to ensure review and annual update of the facility emergency preparedness communication plan.

Findings:

Record review of the emergency preparedness communication plan showed no facility documentation that the communication plan had been updated and reviewed annually for
2014, 2015, or 2017.

On 01/08/18 at 11:17 am, the surveyor asked the facility administrator for documentation that the communication plan had been reviewed and approved annually. The facility administrator provided the communication plan for 2016. The surveyor asked the facility administrator for the approved communication plan for 2017 and the facility administrator stated it did not exist.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that addressed the means in the event of an evacuation, to release patient information to include the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).

Findings:

Record review of the facility emergency preparedness communication plan did not contain methods for sharing information and medical documentation for patients under the facility's care with other health care providers to maintain continuity of care in the event of an evacuation as required.

On 01/09/18 at 1:33 pm the surveyor asked the facility manager for documentation to verify the facility had developed an emergency preparedness communication plan to share information for patients under the facility's care as necessary with other heath care providers in the event of an emergency. The facility manager stated they were unaware of this requirement and had not developed an emergency preparedness communication plan to address sharing information. The facility manager stated the facility would develop a plan to address sharing information in the event of an evacuation.

Based on record review and interview the facility failed to ensure training for individuals providing services under arrangement, and volunteers on the emergency preparedness plan.

Findings:

Record review of the facility emergency preparedness training documentation did not contain the training requirements for volunteers and individuals providing services under arrangement.

On 01/09/18 at 1:47 pm the surveyor asked the human resource administrator, facility administrator and maintenance supervisor for documentation of training in-service for volunteers and individuals providing
services under arrangement. The human resource administrator stated they were unaware this was required for facility volunteers and individuals providing services under arrangement. The training in-service did not exist.

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 as required in accordance with NFPA 101, 2012 Edition, Chapter 19.2.2.2.6.

Findings:

On 01/08/18 at 2:41 pm deadbolt locks was observed on two doors in the facility: ultrasound door room 100 on the south hall and on patient room 106.

On 01/08/18 at 2:41 pm the facility manager stated he would uninstall the existing deadbolt's.

On 01/08/18 at 3:09 pm a barrel latch was observed to be on the recovery room door and doctor's locker room door within the operating room.

On 01/08/18 at 3:19 pm the facility manager stated he will remove the barrel latches before the surveyor leaves the facility.

Based on observation and interview, the facility failed to ensure each exit discharge had emergency generator powered or battery powered backed-up emergency lighting installed as required.

Findings:

On 01/08/18 at 1:20 pm each of the designated exit discharges from the facility were observed to have lighting fixtures on normal power. The following exit discharges did not have emergency powered lighting: main entrance/exit, Emergency Room walk-in entrance/exit with portico, laboratory entrance/exit, south staff/nursing entrance/exit, two basement exit discharges exiting near generator and bulk oxygen.

On 01/08/18 at 2:38 pm the facility manager was asked if the exit discharge lighting would always illuminate when the emergency generator came on and there was no normal electrical power. He stated he did not know and could not confirm which existing light fixtures would illuminate under emergency generator power.

Based on record review and interview, the facility failed to ensure ventilation within the surgical suite was in accordance with ASHRAE 170-2013.

Findings:

Record review showed the facility's annual test and balance inspection reports for 2015, 2016 and 2017 were missing. The test and balance reports did not exist.

Record review showed the facility's surgical suite air quality documentation reports were missing. There was no documentation which included readings of the HVAC manometer serving the surgical suite were read as required for the changing of the air filters based on pressure drop. The air quality manometer documentation reports did not exist.

On 01/08/18 at 1:56 pm the facility manager was asked for the annual test and balance inspection reports for the last three years. He stated they have not been done.

On 01/08/18 at 2:15 pm the facility manager was asked to describe the process in which the air filters that serve the surgical suite are changed. He stated the filters are changed monthly and are also visually checked. He stated if the filters look to be dirty they are also changed.

Based on observation and interview, the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over or within one inch of an ignition source as required.

Findings:

On 01/08/18 at 2:28 pm one ABHR was observed to be installed over an ignition source located in the alcove outside of the facility pharmacy.

On 01/08/18 at 2:28 pm the facility manager was asked when the ABHR was installed and if the substance contained within it was alcohol. He stated yes alcohol is used in it and he did not know the exact time it was installed. He stated he would reinstall it away one inch from an ignition source as required.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with NFPA 70, National Electric Code as required.

Findings:

On 01/08/18 at 2:25 pm a refrigerator holding prescription medications was observed without a current inspection sticker within the emergency room.

On 01/08/18 at 2:25 pm the facility manager stated he would get the Hamilton Beach medication refrigerator added to the list to be inspected.

On 01/08/18 at 2:44 pm a medication refrigerator was observed in the pharmacy to not have a current inspection label.

On 01/08/18 at 2:44 pm the facility manager stated he would get the Amana medication refrigerator added to the list to be inspected.

On 01/08/18 at 3:33 pm a sterilizer located in the surgical suite was observed to have an out of date Department of Labor inspection sticker dated 2013.

On 01/18/18 at 3:34 pm the facility manager stated he would call the department of labor to get the inspection of the sterilizer completed.

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 01/08/18 at 10:25 am the facility manager was asked how they conduct their fire drills. He stated the process and it did not include the verification/documentation of transmission of a fire alarm signal as required.

Based on observation and interview, the facility failed to ensure that space heaters used in non-sleeping staff areas had heating elements which did not exceed 212 degrees Fahrenheit as required in NFPA 101, 2012 Edition, Chapter 19.7.8.

Findings:

On 01/08/18 at 2:27 pm a space heater was observed in the emergency room doctor's sleeping room.

On 01/08/18 at 2:30 pm the facility manager was asked what room the space heater was in which was located near the desk in the emergency room. He stated it was the doctor's sleeping room.

Based on record review and interview, the facility failed to ensure completion of their building systems medical gas system risk assessment as required.

Findings:

Record review did not show the building systems medical gas risk assessment document. The document does not exist.

On 01/08/18 at 10:42 am the surveyor asked the facility manager for the building systems medical gas systems risk assessment documentation and he failed to provide the document.

Based on record review, observation, and interview, the facility failed to ensure isolated power system maintenance and testing was completed at intervals equal to or less than once per month in accordance with NFPA 99, 2012 Edition, Chapter 6.3.2.6.3.6 and records were failed to be kept on hand as required in NFPA 99, 2012 Edition, Chapter 6.3.4.2.2.

Findings:

Record review did not show monthly inspection/testing certifications for the operating rooms line isolation monitors for each month of 2015, 2016, and 2017. The testing/inspection records do not exist.

On 01/08/18 at 3:38 pm the line isolation monitor in operating room #2 was observed to not have a green light illuminated to indicate it to be in proper operating condition.

On 01/08/18 at 3:38 pm the surveyor asked the maintenance supervisor why the green light was not illuminated on the line isolation monitor in operating room #2. He stated that it should be and they have had some problems with it. He stated there must be something wrong with it again and will get it checked.

Based on record review and interview, the facility failed to ensure their building system risk assessment for their essential electrical systems was completed as required.

Findings:

Record review did not show the building systems essential electrical risk assessment. The essential electrical system risk assessment does not exist.

On 01/08/18 at 10:42 am the surveyor asked the facility manager for the building systems essential electrical systems risk assessment documentation and he could not provide the document. The facility manager stated he did not have the essential electrical system risk assessment as it did not exist.

Based on record review and interview, the facility failed to ensure the emergency generator was ran for 30 minutes each month. The facility also failed to ensure annual generator fuel quality testing as required.

Findings:

Record review showed the monthly generator logs for 2015, 2016 and 11 months of 2017 were not included. The generator log documentation does not exist. Only the February 2017 generator log was provided. Also, the annual fuel quality test reports for 2015, 2016 and 2017 was not included. The annual fuel quality test reports do not exist.

On 01/08/18 at 10:43 am the surveyor asked the maintenance supervisor for the monthly generator logs for 2015, 2016 and 2017. He stated that he thought he could get them, and said the staff member who is responsible for them usually prints a screen shot of the Kohler software that indicates the days/times and information on the generator. The maintenance supervisor provided one monthly generator log for February 2017. The maintenance supervisor stated they have not done generator fuel quality testing for 2015, 2016, and just recently sent in a sample to be tested for 2017. He stated the DVM told them they needed to start annual generator fuel testing too.

Based on record review and interview, the facility failed to ensure annual medical gas certification was completed as required in accordance with NFPA 99, 2012 Edition, Chapter 5.

Findings:

Record review showed the annual medical gas certifications for 2015, 2016 and 2017 were missing. The medical gas annual certifications for 2015, 2016, and 2017 do not exist.

On 01/08/18 at 3:00 pm the surveyor interviewed the facility manager and asked for the 2015, 2016 and 2017 annual medical gas systems certifications. He stated they were not done. He stated he can get the annual bulk oxygen inspections documentation but not for the whole medical gas system as it was not done.