HospitalInspections.org

Based on record review and staff interview, the facility did not review and update their emergency preparedness plan at least every two years in accordance with the requirements of 42 CFR 482.15(a).

Findings include:

On 6/4/25 at 10:00am, review of the "Emergency Preparedness Policy" (dated 9/21) revealed the policy was last reviewed and revised on 9/21/21. Interview with the Chief of Quality Services confirmed that the policy was last reviewed in September 2021.

This finding was confirmed with the Chief of Quality Services and Safety Manager at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on record review and staff interview, the facility did not develop a policy or procedure to track and document the location of on-duty staff during and after an emergency in accordance with the requirements of 42 CFR 482.15(b)(2).

Findings include:

On 6/4/25 at 10:05am, review of the "Fort Defiance Indian Hospital Board, Inc Emergency Action Plan 2025 - Adolescent Care Unit (ACU) Roll Call Sheet" revealed the facility did not have a written process in place for documenting the specific name and location of the receiving facility or other location for on-duty staff.

This finding was confirmed with the Safety Manager at time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not maintain the construction classification for the building as required by NFPA 101 - 2012 edition, Sections 19.1.6.1, 4.5.8 and NFPA 220 - 2012 edition, Section 4.1, 4.1.1 and Table 4.1.1.

Findings include:

1. On 6/3/25 at 8:45am, observation in room 1A3-05 electrical room revealed several areas totaling about five square feet in the ceiling where the fire retardant had been removed/damaged exposing the bare steel of the structural I-beams.

2. On 6/4/25 at 7:55am, observation in the lab revealed two holes in the floor approximately one-inch in diameter.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not maintain egress doors in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.2.2.2.4 and 7.2.1.6.1.

Findings include:

1. On 6/4/25 at 9:00am, observation at the exit doors near the cardio area revealed one leaf did not unlatch when the panic bar was pressed preventing the door from opening.

2. On 6/425 at 9:15am, observation at the exit doors in the physical therapy area revealed one leaf did not unlatch when the panic bar was pressed preventing the door from opening.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not maintain doors with self-closing devices in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.2.2.2.7.

Findings include:

1. On 6/3/25 at 2:10pm, observation in room 2B2-03 revealed the door had a self-closing device installed and did not latch when tested three times by the surveyor.

2. On 6/4/25 at 8:00am, observation in room 1D3-07 revealed the door had a self-closing device installed, but was being held open by a doorstop.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not properly install alcohol-based hand rub (ABHR) dispensers in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.3.2.6.

Findings include:

1. On 6/3/25 at 4:15pm, observation in the "Fastrak" area revealed an ABHR dispenser installed directly above an outlet.

2. On 6/4/25 at 8:00am, observation in room 1D3-07 revealed an ABHR dispenser installed directly above a light switch.

3. On 6/4/25 at 11:20am, observation outside room 2C3-06 revealed an ABHR dispenser installed directly above a light switch.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not maintain the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 18.3.4 and 9.6 and NFPA 72 - 2010 edition.

Findings include:

On 6/4/25 at 2:35pm, observation in the main electrical room revealed the circuit disconnect for the fire alarm did not have red identification.

This finding was confirmed with the Chief of Quality Services and Nahata Dzil Health Center Maintenance Mechanical Leader at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation, record review, and staff interview, the facility did not maintain the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 18.3.4 and 9.6 and NFPA 72 - 2010 edition.

Findings include:

1. On 6/3/25 at 3:25pm, observation in room 1B1-11 revealed flatten storage boxes were piled up directly in front of a pull station.

2. On 6/3/25 at 3:35pm, observation in the main electrical room revealed the circuit disconnect for the fire alarm did not have red identification.

3. On 6/4/25 at 9:45am, review of the annual fire alarm inspection reports revealed that the facility did not have an annual inspection of the fire alarm in 2024.

4. On 6/4/25 at 9:50am, review of the annual fire alarm inspection reports revealed that a horn ("2B1-47") failed on the 10/2/23 annual inspection and the 3/20/25 annual inspection and no documentation to show that the horn had been repaired at any point.

5. On 6/4/25 at 11:25am, observation in the Operating Room corridor near room 2C3-02 revealed a horn/strobe was blocked by a supply cart parked in the corridor.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation, record review, and staff interview, the facility did not maintain its automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5, 9.7 and NFPA 25 - 2011 edition.

Findings include:

1. On 6/3/25 at 3:15pm, observation in room 1E2-08 revealed oxygen supplies were stored on shelves within 18 inches of the sprinkler.

2. On 6/3/25 at 3:20pm, observation in room 1B3-09 revealed chemical supplies were stored on shelves within 18 inches of the sprinkler.

3. On 6/3/25 at 4:10pm, observation in the kitchen revealed a heavy accumulation of dust buildup on the sprinklers in Fridge 1 and Fridge 2.

4. On 6/4/25 at 7:55am, observation in the Laboratory in the main workstation area revealed a sprinkler missing an escutcheon ring.

5. On 6/4/25 at 8:05am, observation in room 1E3-17 revealed a sprinkler missing an escutcheon ring.

6. On 6/4/25 at 9:30am, review of the annual sprinkler reports revealed that a pressure gauge ("D2 Sectional") failed on the 3/30/23, 4/30/24, and 3/30/25 annual inspections and no documentation to show that the pressure gauge had been repaired/replaced at any point.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not ensure fire extinguishers were maintained in accordance with NFPA 101 - 2012 Edition, Sections 19.3.5.12, 9.7.4.1 and NFPA 10 - 2010 Edition, Section 7.3.

Findings include:

On 6/4/25 at 2:40pm, observation in the staff kitchen revealed the K extinguisher had a pressure indicator in the overcharge zone.

This finding was confirmed with the Chief of Quality Services and Nahata Dzil Health Center Maintenance Mechanical Leader at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not ensure fire extinguishers were maintained in accordance with NFPA 101 - 2012 Edition, Sections 19.3.5.12, 9.7.4.1 and NFPA 10 - 2010 Edition, Section 7.3.

Findings include:

On 6/4/25 at 9:10am, observation in the main lobby area revealed the fire extinguisher tags were missing monthly inspection signoffs.

This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not provide corridor doors in accordance with the requirements of NFPA 101-2012 edition, Sections 19.3.6.3, 19.3.6.3.1 and 19.3.6.3.5.

Findings include:

1. On 6/4/25 at 7:30am, observation in the corridor near room 1B5-21 revealed an approximate quarter-inch hole in the door above the lock.

2. On 6/4/25 at 7:35am, observation in room 1B5-15 revealed a quarter-inch hole in the oxygen room door.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not ensure that smoke barrier walls were maintained in accordance with the requirements of NFPA 101-2012 edition, Sections 19.3.7, 19.3.7.1, 19.3.7.3, 8.5, 8.5.2, 5.5.2.1, 8.5.2.2, 8.5.2.3 and 8.5.6.

Findings include:

1. On 6/3/25 at 4:05pm, observation in room 1B3-12 revealed pipe penetrations that were not properly firestopped.

2. On 6/4/25 at 10:40am, observation at the smoke barrier near room 2C3-17 revealed a pipe penetration that was firestopped with greyish material. Interview with the Facility Manager and Director of Facilities at the same time as observation revealed they were not able to confirm if the greyish material had a fire-rating.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and interview, the facility did not maintain clearances around electrical panels in accordance with NFPA 101 - 2012 edition, Section 9.1.2 and NFPA 70 - 2011 edition, Section 110.

Findings include:

On 6/3/25 at 2:00pm, observation in room 2B1-38 revealed ladders stored directly in front of emergency electrical panels.

This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on record review and staff interview, the facility did not perform fire drills once per shift per quarter and did not transmit the fire alarm signal during all fire drills in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.7.1.

Findings include:

1. On 6/3/25 at 12:40pm, review of the "Fire Drill Policy" (revised 9/20/24) revealed the policy states "a minimum of one fire drill per shift per quarter". Interview with the Safety Manager at the same time as record review revealed the facility had reduced the frequency of the fire drills down to four times per year. When requested to provide the policy documentation that allowed for this reduction in fire drills, the facility was unable to provide the policy.

2. On 6/5/25 at 9:20am, review of the fire drill records revealed the facility conducted silent/coded drills (no transmission of the fire alarm) outside of the allowed nocturnal hours of 9:00pm-6:00am on the third shift of the fourth quarter of 2024 (Oct-Dec) and the first and second shift of the first quarter of 2025 (Jan-Mar).

These findings were confirmed with the Chief of Quality Services and Safety Manager at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation, record review, and staff interview, the facility did not maintain fire door assemblies in accordance with NFPA 101 - 2012 edition, Sections 8.3.3.1 and 19.7.6, and NFPA 80 - 2010 edition, Section 5.2.4.

Findings include:

1. On 6/3/25 at 2:05pm, observation in Labor and Delivery near room 2B2-16 revealed holes in the cross-corridor fire doors.

2. On 6/5/25 at 9:25am, review of the annual fire door inspection report performed on 9/12/24 revealed 20 doors failed inspection and had not been corrected/replaced.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not protect wet procedure locations in accordance with NFPA 99 - 2012 edition, Sections 6.3.2.2.8.4, 6.3.2.2.8.7, and 6.4.4.2.

Findings include:

On 6/4/25 at 11:30am, observation in the Operating Room department revealed none of the operating rooms had ground-fault circuit interrupters installed on the outlets. Interview with the Facility Manager and Director of Facilities at the same time as observation revealed the operating rooms were not protected by an isolated power circuit interrupter nor did the facility have a risk assessment that classified the operating rooms as a non-wet procedure location.

This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not provide functional remote annunciator panels for the essential electric system (EES) in accordance with NFPA 99 - 2012 edition, Section 6.4.1.1.17.

Findings include:

On 6/4/25 at 2:50pm, observation revealed neither of the two remote annunciators for the emergency generator in the building were functioning when the lamp test button was pressed.

This finding was confirmed with the Chief of Quality Services and Nahata Dzil Health Center Maintenance Mechanical Leader at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on record review and staff interview, the facility did not maintain the emergency electrical system in accordance with the requirements of NFPA 101 -2012 edition, Section 19.5.1, 9.1, 9.1.3.1 and NFPA 110 - 2010 edition, Section 8.4.9.

Findings include:

On 6/5/25 at 9:10am, review of the annual generator preventative maintenance reports revealed that the two-hour loadbank test for Gen 3 on 12/7/24 ended after 1 hour 10 mins. The facility was able to provide documentation that repairs were made to Gen 3, but no loadbank retest was performed.

This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not properly utilize power strips in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.2 and NFPA 70, 2011 Edition, Sections 400.7(B) and 400.8(1).

Findings include:

On 6/4/25 at 7:35am, observation in the corridor outside room 1B5-15 revealed a crash card plugged into a powerstrip that was plugged into an outdoor extension cord ("daisy chained")

This finding was confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the time of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on observation and staff interview, the facility did not store gas cylinders in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.3.2.4, 8.7 and NFPA 99 - 2012 edition, Section 11.3.

Findings include:

1. On 6/3/25 at 3:15pm, observation in room 1E2-08 revealed four oxygen cylinders that were mixed and not separated into full any empty cylinders.

2. On 6/3/25 at 4:00pm, observation in room 1B3-13 revealed three nitrous oxide tanks stored upright on the floor and not secured.

3. On 6/4/25 at 7:35am, observation in room 1B5-15 revealed an empty oxygen cylinder with a vendor tag indicating the cylinder was still full.

These findings were confirmed with the Chief of Quality Services, Facility Manager, Director of Facilities, and Computer Maintenance Management Systems Quality Coordinator at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.

Based on record review and staff interview, the facility did not establish emergency procedures for operating room emergencies in accordance with the requirements of NFPA 99 - 2012 edition, Section 15.13.

Findings include:

1. On 6/4/25 at 11:38am, review of the "Safety practices in the OR" policy (dated 11/20) revealed the policy did not include procedures outlining safety precautions related to the use of flammable liquids, germicides or antiseptics when there is use of electrosurgery or cautery. Interview with the Interim Nurse Executive Officer confirmed that the operating room staff do complete electrosurgery and utilize cautery equipment routinely.

2. On 6/4/25 at 11:40am, interview with the Interim Nurse Executive Officer revealed that prior to surgeries, a time-out is completed as part of the operating room safety practices. The Interim Nurse Executive Officer confirmed that the "Safety practices in the OR" is the only policy for the operating room that addresses fire safety but the policy does not outline time-out safety checks for flammable liquid use or specific emergency procedures for the operating room including alarm actuation, evacuation, chemical spills, and equipment shutdown procedures.

3. On 6/4/25 at 11:45am, interview with the Interim Nurse Executive Officer revealed that staff in the operating room utilize saline or a fire extinguisher in the event of a fire. The Interim Nurse Executive Officer confirmed that the current "Safety practices in the OR" policy does not include emergency procedures for extinguishing drapery, clothing or equipment fires.

4. On 6/3/25 at 9:00am, review of fire drill records provided by the Safety Manager revealed that the operating room has not had an annual exit drill. Interview with the Interim Nurse Executive Officer on 6/4/25 at 11:40am confirmed annual exit drills were not conducted.

These findings were confirmed with the Chief of Quality Services and Acting Chief Nursing Officer at the times of discovery and reviewed with the Chief Executive Officer, Chief Medical Officer, Acting Chief Nursing Officer, Chief Administrative Officer, and Chief of Quality Services at the exit conference.