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Based on record review and interview, the facility failed to ensure the emergency operations plan included a means for sheltering staff and volunteers remaining in the facility during disaster events.


Findings:


Record review showed the facility documentation included a generalized sheltering in place policy not specific to the facility location. The policy did not include each required component. A location specific policy document did not exist. The facility did not provide an emergency operations plan which included a means for sheltering all patients, staff, and volunteers who remain in the facility in the event that an evacuation cannot be executed. The Policy titled "Emergency Operations Plan " did not address the following :

~shelter in place for staff and volunteers who remain in a facility.

~sheltering in place which align with the facility's risk assessment.


On 05/15/18 at 2:00 pm, the surveyor requested policies from Staff V for the emergency preparedness plan, which included sheltering in place. The policy titled, "Integris Health Emergency Operations Plan" was provided. On page 8 of 13 under the evacuation protocols, stated, "INTEGRIS has defined procedures for relocating patients within the hospital to safe areas in adjacent smoke compartments or designated severe weather shelter areas". Staff V stated, the facility uses the same policies as Integris Bass Baptist hospital. The surveyor informed Staff V if the facility is a part of the integrated policies developed by Integris Bass Baptist hospital, they would need to show the policies are specific to Bass Pavilion. No evidence was provided that showed the facility was specific to the hospital. The documents for sheltering in place and the required components were not available because they did not exist.

Based on record review and interview, the facility failed to ensure annual in-service training for staff and individuals providing services under arrangement, on the emergency preparedness plan for four (staff Y, staff LL, staff TT, and staff VV) of 13 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual in-service training for existing staff, and individuals providing services under arrangement for the following:

· Staff Y, who worked as an CNA with the date of hire 09/24/14, had not received annual in-service training for emergency preparedness 2015 and 2016.
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· Staff LL, who worked as an diabetes Registered Nurse with the date of hire 05/09/14, had not received annual in-service training for emergency preparedness 2015 and 2016.
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· Staff TT, who worked as medical doctor, had not received annual in-service training for emergency preparedness for 2015 and 2016. No date of hire was given to the surveyor by the medical staff service system manager.
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· Staff VV, who worked as medical doctor, had not received annual in-service training for emergency preparedness for 2015 and 2016. No date of hire was given to the surveyor by the medical staff service system manager.
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· The training documentation for Staff Y, Staff LL, Staff TT and Staff VV was not available because it did not exist.
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On 05/15/18 at 10:11 am, the surveyor asked Staff Q and Staff C for documentation of training in-service for new, existing staff members, volunteers, and individuals providing services under arrangement. Staff Q and Staff C stated, the emergency preparedness documentation for training in-service was not available because the facility was not aware of this requirement for emergency preparedness training.

Based on record review and interview, the facility failed to demonstrate education and instruction to staff, contractors, and facility volunteers.


Review of the facility emergency preparedness training documentation, showed no documentation of the tabletop exercise, community based exercise, or full-scale exercise to demonstrate staff knowledge of emergency procedures because the documentation did not exist for drills and or exercises to test the emergency plan identifying gaps and areas for improvement.


On 5/16/18 surveyor requested the Director of facility Services for documentation such as a sign-in sheet, meeting minutes, to verify staff received training on drills or exercises completed by the facility. The Director of facility Services stated, the facility could pull time cards for the days the exercises were conducted. The surveyor stated, CMS requires facilities to be able to demonstrate documentation exist for training for drills and exercises for staff to test the emergency plan identifying gaps and areas for improvement. The document did not exist.

Based on record review and interview, the facility failed to (including services from the main hospital operating under a separate CMS number) demonstrate the facility actively participated in the development of the unified and integrated emergency preparedness program.


Findings:


Record review of the facility emergency preparedness training showed, Integris Bass Pavilion is part of an integrated healthcare system, operating under a separate CMS CCN number. The facility could not demonstrate they actively participated in the development of the unified and integrated emergency preparedness program, because the documentation did not exist.


On 5/15/2018 at 2:17 pm, the surveyor asked Staff V for documentation showing the facility actively participated in the development of the unified and integrated emergency preparedness program. Staff V stated, he was unaware of this requirement and was unable to provide the documentation because it did not exist.


On 5/15/18 at 2:23 pm, the surveyor asked Staff V, Staff W, and Staff O for the Emergency Preparedness policies specific to the hospital and approved by the governing body. The Staff W stated, the facility utilized the policies from Integris Bass Baptist Hospital. The surveyor stated the emergency preparedness policies should be specific to Bass Pavilion. The facility did not show that their emergency preparedness policies are specific to their hospital which is operating under a different CMS CCN number.


The following facility policy and procedures did not provide evidence the policy was specific to the hospital and approved by the governing board:

~Emergency Operations Plan

~Environment of Care Management Plan

~Emergency Standard Operating Procedure (Code Black)(Code Yellow)(Code Red)(Code White)

~Credentialing for Disaster

Based on observation and interview, the facility failed to ensure a required means of egress was not equipped with a deadbolt lock that requires two actions to open from the egress side.

Findings:

On 05/15/18 at 2:11 pm, two deadbolts were observed to be on two doors at the southside pharmacy. One deadbolt was on the corridor door, and the second deadbolt was on an adjoining door inside the southside pharmacy going into a different area. The deadbolts installed on each of the doors would require two actions to open instead of the required one action.

On 05/15/18 at 2:31 pm, Staff V was asked why the deadbolts were installed on the doors of the southside pharmacy. Staff V asked if there was a different requirement which would allow the locks and the surveyor stated, no. The surveyor explained egress requires one action to egress to be in compliance with code.

Based on record review, observation, and interview, the facility failed to ensure ventilation is in accordance with ASHRAE 170.

Findings:

Record review showed the facility ventilation documentation for isolation room #4228 did not include air exchanges per hour as required.

On 05/15/18 at 2:15 pm, the surveyor asked Staff V for the 2015, 2016, and 2017 annual test and balance inspection reports for the isolation room(s). Staff V stated, they do the tissue test to confirm the isolation room is negative and stated they do not have that documentation regarding air changes per hour and the test and balance inspection documentation for isolation room #4228 to confirm air exchanges per hour does not exist.


On 05/14/18 at 2:28 pm, a steel four shelve storage rack was observed directly in contact with a electrical breaker panel in an electrical closet. The steel storage rack had sterile supplies stored on each of the four shelves. The room was observed to have no positive ventilation which is required for the storage of sterile supplies.

On 05/14/18 at 2:30 pm, the surveyor asked Staff V why the sterile supplies were being stored in the electrical closet. Staff V stated, they have very limited storage space but will correct the issue.

Based on record review and interview, the facility failed to ensure smoke detector sensitivity inspection, testing, and maintenance.


Findings:


Record review of fire alarm system inspection reports showed no smoke detector sensitivity testing was completed for 2014, 2015, 2016, 2017, and Jan.- May of 2018 because the smoke detector sensitivity testing documentation does not exist.


On 05/15/18 at 10:08 am, the surveyor asked Staff V for the smoke detector sensitivity testing for 2014, 2015, 2016, 2017, and 2018, and the initial when the detectors were installed. Staff V stated, they did not have the smoke detector sensitivity testing documentation because the smoke detector sensitivity testing documentation does not exist.


NFPA 72, 2010 Edition

Chapter 14 Inspection, Testing, and Maintenance

14.1 Application

14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.

14.1.4 The requirements of this chapter shall apply to both new and existing systems.

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless permitted by compliance with 14.4.5.3.3.

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range ( or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

Based on observation, record review, and interview, the facility failed to ensure the sprinkler system was inspected, tested, and maintained as required.



Findings:

On 05/15/18 at 3:40 pm, the facility sprinkler system was observed to be totally comprised of metallic piping.

Record review showed the fire sprinkler system inspection documentation did not include a five year internal inspection of sprinkler piping report because the documentation does not exist.

On 05/15/18 at 3:45 pm, the surveyor asked Staff V for the five year internal inspection of the sprinkler piping report. Staff V stated, they have not done the inspection.



NFPA 25, 2011 Edition

Chapter 14 Obstruction Investigation

14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4, an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.

14.2.1.1 Alternative nondestructive examination methods shall be permitted.

14.2.1.2 Tubercles or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).

14.2.1.3* If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described in Section 14.3.

14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.

Based on observation and interview, the facility failed to provide smoke barriers constructed to provide at least one-half hour fire resistance rating as required.

Findings:

On 05/17/18 at 3:41 pm, the surveyor observed a patient room repurposed into a hazardous area storage closet for combustible medical supplies. The east wall was observed to have a square penetration where a clock once had been installed and was removed but not replaced leaving an opening into the wall where smoke/fire could travel into the rest of the building.


On 05/17/18 at 3:41 pm, Staff V stated, they would get the hole fixed.


On 05/17/18 at 4:03 pm, the surveyor observed a approximately two inch circular hole in the smoke barrier wall in the plenum space above the drop ceiling located near the soiled linen closet on the second floor.


On 05/17/18 at 4:03 pm, Staff V stated, since the drop ceiling was in place and smoke tight, he did not think any holes in wall above the smoke tight ceiling tiles would need to be repaired. The surveyor stated, corridor walls which are installed are to be maintained and/or repaired.

Based on observation and interview, the facility failed to ensure electrical closets were maintained clear for working space.


Findings:


On 05/14/18 at 2:28 pm, a steel four shelve storage rack was observed directly in contact with a electrical breaker panel in an electrical closet. Code requires 36 inches clear in front of electrical panels and 30 inches clear to each side of electrical panels.


On 05/14/18 at 2:30 pm, the surveyor asked Staff V why the sterile supplies were being stored in the electrical closet. Staff V stated, they have very limited storage space but will correct the issue.

Based on record review and interview, the facility failed to ensure elevators were inspected and tested.

Findings:

Record review showed the Department of Labor annual inspection certificate for the east elevator was inspected on 03/31/17 and is not current after 03/31/18.

On 05/16/18 at 1:32 pm, the surveyor asked Staff V if there was another certificate which was current for the east elevator. Staff V stated, no he did not think so.

Based on record review and interview, the facility failed to ensure fire drill exercises were conducted as required.


Findings:


Record review showed two fire drills - one in 2016 and the second on in 2017 did not document that actual fire drill exercises were performed/conducted. The fire drill document dated 11/08/16 for 3rd shift and the fire drill document dated 04/19/17 for 2nd shift showed, the security guard who evaluates the fire drill exercise documented, he only orally questioned the participants instead of having the participants physically demonstrate how they would perform in an actual fire as required.


On 05/14/18 at 11:17 am, the surveyor stated to Staff V, the facility fire alarm drills should include a fire drill staff exercise for them to demonstrate proficiency. Staff V stated, he understands and they will ensure fire drills are actually performed as required.

Based on record review and interview, the facility failed to ensure the annual fire rated door assembly annual inspections were completed.


Findings:


Record review showed, the annual fire rated door assembly inspections for 2017 were not completed because the 2017 annual fire rated door assembly inspection documentation does not exist.


On 05/15/18 at 3:35 pm, the surveyor asked Staff V for the annual fire rated door assembly inspections. Staff V stated, the inspection was not completed for 2017 and the documentation did not exist.

Based on record review and interview, the facility failed to ensure the medical gas and essential electrical system (EES) building system risk assessments were completed for their existing facility.


Findings:


Record review showed, the facility medical gas building system risk assessments were not completed because the documentation does not exist.


Record review showed the EES building system risk assessments were not completed because the documentation did not exist.


On 05/14/18 at 1:17 pm, the surveyor asked Staff V for the medical gas building system risk assessments. Staff V stated, the assessment was not conducted and the documentation did not exist.


On 05/14/18 at 1:17 pm, during record review the surveyor asked Staff V for the EES building system risk assessment, he stated, the assessment was not conducted and the document does not exist.



NFPA 99, 2012 Edition

Chapter 5

5.1.1.1, 5.2.1, 5.3.1.1, 5.3.1.5

Gas and Vacuum Piped Systems - Categories

Medical gas, medical air, surgical vacuum, WAGD, and supply air systems are designated:

o Category 1 - Systems in which failure is likely to cause major injury or death.

o Category 2 - Systems in which failure is likely to cause minor injury.

o Category 3 - Systems in which failure is not likely to cause injury, but can cause discomfort.


NFPA 99, 2012 Edition

3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1, TIA 12-3

Electrical Systems - Essential Electric System Categories

*Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES.

*General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES.

*Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours.

Based on record review and interview, the facility failed to ensure the annual emergency generator fuel quality testing was completed and maintenance was completed on generator transfer switch.


Findings:


Record review showed, the annual emergency generator fuel quality testing reports were not completed for 2015, 2016, and 2017, as the documents do not exist.


Record review showed, the facility generator inspection reports did not include maintenance of the generator transfer switch.


On 05/14/18 at 1:52 pm, Staff V was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016, and 2017. Staff V stated, the annual emergency generator fuel quality tests have never been done and the documents do not exist. The surveyor asked Staff V for the maintenance records for the emergency generator transfer switch. Staff V stated, the transfer switch maintenance had not been done but will be scheduled.

Based on observation and interview, the facility failed to ensure all patient care related electrical equipment was tested and inspected before being placed into service.


Findings


On 05/15/18 at 12:11 pm, an in-service vital sign machine was observed to have an inspection sticker showing an out of date inspection, it showed its next inspection was due on 03/20/2018.


On 05/15/18 at 12:13 pm, two in-service CPAP machines were observed to not be currently inspected.


On 05/15/18 at 12:15 pm, a vital sign machine and Hudson RCI Neptune was observed to not be currently inspected.


On 05/15/18 at 2:37 pm, a medication refrigerator on the second floor was observed to not be curently inspected.


On 05/15/18 at 2:38 pm, the surveyor asked Staff V what the process is for their biomedical vendor in regards to currrent inspections for their biomedical equipment. Staff V stated, they place inspection stickers on the equipment which indicates the equipment is current.

Based on record review, observation, and interview, the facility failed to ensure medical gas cylinders were maintained and no items were stored in a room containing medical gasses.


Findings:


Record review of the facility medical gas inspection reports showed no documentation of medical gas cylinders in use within the facility were current on required testing because the documentation does not exist.


On 05/16/18 at 1:15 pm, the surveyor observed a plastic yellow container of ethylene glycol stored in the medical gas room near the emergency generator.


On 05/16/18 at 1:30 pm, the surveyor asked Staff V for the maintenance, inspection and testing report documents indicating the in-service medical gas cylinders are in compliance. Staff V stated, the facility does not have those, they have a vendor who they lease the medical gas cylinders from. The surveyor stated it is the facility's responsibility to have or request from the vendor the maintenance documentation to show cylinders are in compliance before being placed into service. Staff V stated, he would get with their vendor to obtain the necessary documentation.



NFPA 99, 2012 Edition

Chapter 5 Gas and Vacuum Systems

5.3.10 Compressed Gas Cylinders and Containers

5.3.10.1 Only cylinders and containers constructed, tested, and maintained in accordance with U.S. Department of Transportation specifications and regulations shall be permitted to be used.

Based on record review and interview, the facility failed to ensure initial and ongoing staff training on safety measures, handling, and specific hazards of medical gases usage/guidelines for six of six staff members.


Findings:


Record review of physical/occupational therapy staff human resources training folders for Staff 1, Staff 2, Staff 3, Staff 4, Staff 5, and Staff 6, showed each did not have documentation of being trained on the safety, handling, proper filling procedures for liquid oxygen or continuing education for transfilling liquid oxygen because the training records do not exist.


On 05/15/18 at 2:27 pm, Staff V was asked who uses the liquid oxygen. He stated, it is used for patients who go into the occupational/physical therapy department. The surveyor asked Staff V who all does the transfilling. He stated, the physical/occupational therapy staff.


On 05/15/18 at 2:45 pm, the surveyor asked Staff 1 and Staff 2 if they have received any training on transfilling liquid oxygen. They both stated, yes and that their old boss trained them on the safety measures on transfilling liquid oxygen in addition to the related safety concerns. The surveyor asked the Staff 1 and Staff 2 for the training record documentation and each of them stated it should be in their personnel files. The surveyor asked Staff 1 to describe the process of the transfilling process. She stated, she would go over to the closet where they kept the liquid oxygen, open the door, hook up the bottles, turn the valve, watch the gauge then turn it off. The surveyor asked if the door to the room housing the liquid oxygen would be open or closed when the transfilling would be taking place. She stated, the door would be open. The surveyor asked Staff 1 who refills the large liquid oxygen tank for them to refill the smaller tanks. She stated, the medical gas vendor comes and refills it.


Gas Equipment - Qualifications and Training of Personnel

Personnel concerned with the application, maintenance, and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. (11.5.2.1 (NFPA 99)

Based on observation and interview, the facility failed to ensure transfilling of pressurized liquid medical gas was done in a protected area.


Findings:


On 05/15/18 at 2:00 pm, an unsecured, approximately ten gallon liquid oxygen container on wheels, was observed in the second floor housekeeping closet. The floor of the housekeeping closet was observed to have combustible tiles and not ceramic or concrete flooring as required.


On 05/15/18 at 2:45 pm, Staff 1 was interviewed and asked if they have received any training on transfilling liquid oxygen. Staff 1 stated, yes her old boss trained her on the safety measures on transfilling liquid oxygen and the related safety concerns with hazards. The surveyor asked her for the training record documentation and she stated, it should be in her personnel file. The surveyor asked her to describe the process of the transfilling process. She stated, she would go over to the housekeeping closet where they kept the liquid oxygen, open the door, hook up the bottles, turn the valve, watch the gauge then turn it off. The surveyor asked if the door to the room housing the liquid oxygen would be open or closed when the transfilling would be taking place. She stated, the door would be open.


Gas Equipment - Transfilling Cylinders

Transfilling of oxygen from one cylinder to another is in accordance with CGA P-2.5, Transfilling of High Pressure Gaseous Oxygen Used for Respiration. Transfilling of any gas from one cylinder to another is prohibited in patient care rooms. Transfilling to liquid oxygen containers or to portable containers over 50 psi comply with conditions under 11.5.2.3.1 (NFPA 99). Transfilling to liquid oxygen containers or to portable containers under 50 psi comply with conditions under 11.5.2.3.2 (NFPA 99). (11.5.2.2 (NFPA 99)

Based on observation and interview, the facility failed to ensure proper storage of the facility's liquid oxygen base reserve container used for transfilling of pressurized liquid oxygen.


Findings:


On 05/15/2018 at 2:00 pm, an unsecured, approximately ten gallon liquid oxygen container on wheels, was observed stored in the second floor housekeeping closet near the physical/occupational therapy department. NFPA code requires all medical gas containers to be properly secured. The floor of the housekeeping closet was observed to have combustible tiles and not ceramic or concrete flooring as required. A metal paper towel dispenser was observed on the wall of the housekeeping closet which was filled with combustible paper towels. There was a combustible plastic "wet floor" sign observed stored in the housekeeping closet.


On 05/15/2018 at 2:00 pm, Staff V stated, the liquid oxygen tank will be moved to an appropriate area which meets code requirements. The surveyor asked why the liquid oxygen was placed in a housekeeping closet. Staff V stated, he did not know.