The Joint Commission SAFER Matrix

Transcription

1 ITL The Joint Commission SAFER Matrix Program: Hospital Likelihood to harm a Patient / Visitor / Staff High M o d e r a t e L o w EC EP 15 [2] (MRI Access and Door propped) EC EP 5 [1] (No eyewash for bleach use) EC EP 9 [1] LIM circuit breaker panel schedule blank EC EP 15 [6] (Temp/Humid, air flow, sterile processing negative to the corridor) EC EP 5 [17] (Dishwasher Temp issue) EC EP 1 [4] (Pull cord, Beds, Plast Bags, handrails) IC EP 1 [4] (Ice Mach, pot sink chemical low, scale on dishwasher, ice machine not draining and drain tray visibly soiled, Two dusty air vents in C-Section OR.) LS EP 11 [2] (Fire doors wont latch) LS EP 14 [1] (gaps in the baffles of hood ventilation system) EC EP 6 [1] (cigarette butts at main entrance) EC EP 4 [1] (no biohazard signage on an empty circumcision bin) EC EP 5 [3] (Eye Wash Blocked, Not Inspected, Emergency shower not inspected) EC EP 9 [1] licensed independent practitioners role missing in written fire response plan. EC EP 1 [1] (Fire. Drill outside of +/- 10 days) EC EP 3 [1] (Fire alarm(drill) not transmitted at night) EC EP 1 [1] (Sprk PM outside of +/- 10 days) EC EP 28 [1] (NFPA standard reference missing/wrong) EC EP 2 [1] (BP Units not inventoried) EC EP 4 [1] (Sterilizer PM > +/- 10 days) EC EP 9 [5] (Red & Unlabeled breaker) EC EP 23 [3] (Power strip) EC EP 11 [1] (EPSS remote stop location) EC EP 24 [1] (Ext cord) EC EP 6 [7] (Jbox, icebuildup, Panel blocked) EC EP 8 [3] (Improper circuits on LS branch) EC EP 1 [2] (Ex. Sign inventory missing) EC EP 11 [2] (Med Gas Pipe label, emergency gas shutoff valve blocked by sink) EC EP 12 [2] (O2 Bottles not tagged) EC EP 14 [2] Med Air used for Instrum air, Emergency O2 connection sign) EC EP 26 [1] Waiting room chair had cracked upholstery. LDRP Room - worn and chipped arms and upholstery was worn and torn. EC EP 3 [3] (MIFU not followed for cleaning {hydrocollators, CS Sterilizer}, expired thermometers; thermometers with cracked cases) EC EP 1 [7] (NC devices missing in bathrooms) EC EP 1 [1] (fire drills) EC EP 28 [1] (NFPA standard reference missing/wrong) EC EP 1 [74] (Ligature issues) [2] (stained ceiling tiles) [2] Bath pull cord > 6" from floor/wrapped around bar; two light fixtures containing dead bugs. LS EP 13 [7] (Corridor dr latch, Fire dr latch) EC EP 1 [25] (Ligature issues) [4] (ceiling tiles) EC EP 5 [1] (Dishwasher Temps/Chemical Test strips) EC EP 1 [14] (Ligature issues) LS EP 13 [8](Corridor door latches) Organization: Ballad Health 1 of 14 Preliminary Report:

2 p y EC EP 2 [1] (Kitchen TM fire resp. knowledge) IC EP 1 [1] ice machine was noted to have a prominent chemical residue in the tray. LS EP 3 [1] (Smk wall label) LS EP 6 [1] (Suite door lower latches removed) LS EP 11 [1] (90min Dbl Drs wont close) LS EP 12 [1] Exits discharge LS EP 41 [2] (NO EXIT sign missing) LS EP 3 [1] (Haz Rm door latch, ceiling tiles) LS EP 13 [1] (smoke barrier door latch) LS EP 19 [7] (Barrier Penetration and gaps) LS EP 20 [3] (Fire/Smk door gaps/ latch) LS EP 10 [2] (FirePull blocked, key unavailable) LS EP 4 [3] (wire on Sprk Pipe) LS EP 14 [4] Ceiling tiles missing) LS EP 6 [1] (Trash container >32 gallons) The Joint Commission SAFER Matrix Program: Hospital Pattern Widespread Scope Organization: Ballad Health 2 of 14 Preliminary Report:

3 EC EP SAFER Placement Moderate 14 EC Low EC Low EP Text Observation CoP CoP Score The hospital manages magnetic resonance imaging (MRI) safety risks associated with the following: - Patients who may experience claustrophobia, anxiety, or emotional distress - Patients who may require urgent or emergent medical care - Patients with medical implants, devices, or imbedded metallic foreign objects (such as shrapnel) - Ferromagnetic objects entering the MRI environment - Acoustic noise The hospital takes action to maintain compliance with its smoking policy. The hospital implements its procedures in response to hazardous material and waste spills or exposures. (See also IC , EP 2) 1.) Staff allowed surveyor and hosptial leadership int the mobile MRI unit without screening even after prompting by surveyor. 2.) Door between MRI zones 3&4 was propped open. ILSM put in place until issues could be corrected. 1.) Main entrance to hospital was littered with cigarette butts 1.) No biohazard signage on an empty circumcision bin (a) N/A N/A EC Moderate EC Low EC Low The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals. The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals. The written fire response plan describes the specific roles of staff and licensed independent practitioners at and away from a fire's point of origin, including when and how to sound and report fire alarms, how to contain smoke and fire, how to use a fire extinguisher, how to assist and relocate patients, and how to evacuate to areas of refuge. Staff and licensed independent practitioners are periodically instructed on and kept informed of their duties under the plan. A copy of the plan is readily available with the telephone operator or security. Note: For full text, refer to NFPA : 18/19.7.1; ) Bleach used in BHS laundry room with no eye wash station available (a) ILSM is for portable eyewash station to be used until permanent unit is installed. 1.) Kitchen, dish room - the eye wash station was blocked by a food cart (a) Note this finding was corrected during the survey. 2.) Clean Core outside OR1 the weekly eye wash inspection not done one week 3.) Decontamination showers have not been checked by nursing or facilities. 1.) The role of the licensed independent practitioners was not specified in the written fire response plan. This was corrected during the survey. EC Low Pattern The hospital conducts fire drills once per shift per quarter in each building defined as a health care occupancy by the Life Safety Code. The hospital conducts quarterly fire drills in each building defined as an ambulatory health care occupancy by the Life Safety Code. (See also LS , EP 11; LS , EP 6; LS , EP 6) Note 1: Evacuation of patients during drills is not required. Note 2: When drills are conducted between 9:00 P.M. and 6:00 A.M., the hospital may use alternative methods to notify staff instead of activating audible alarms. Note 3: In leased or rented facilities, drills need be conducted only in areas of the building that the hospital occupies. 1.) The organization was conducting fire drills on a 2 shift schedule during Some of the employees was scheduled to work on a 3 shifts. There were no fire drills conducted that covered the 2nd shift employees during the 1st, 2nd, or 3rd quarter of ) In 1 out of 15 Fire Drills performed from Jan 2017 thru Mar 2018, it was noted that it was performed outside of the 3 months +/- 10 days from the last drill requirement. Organization: Johnston Memorial Hospital 3 of 14 Preliminary Report: Posted 3/9/2018

4 EC Low When quarterly fire drills are required, they are unannounced and held at During the third shift fire drills, the fire unexpected times and under varying conditions. Fire drills include alarm signal is not being transmitted. transmission of fire alarm signal and simulation of emergency fire conditions. Note 1: When drills are conducted between 9:00 P.M. and 6:00 A.M., the hospital may use alternative methods to notify staff instead of activating audible alarms. Note 2: For full text, refer to NFPA : 18/19: 7.1.7; 7.1; 7.2; 7.3. EC Low At least quarterly, the hospital tests supervisory signal devices on the inventory 1.) Supervisory signals were not tested within the required quarterly +/ (d)(2) (except valve tamper switches). The results and completion dates are day requirement in documented. Note 1: For additional guidance on performing tests, see NFPA : Table Note 2: Supervisory signals include the following: control valves; pressure supervisory; pressure tank, pressure supervisory for a dry pipe (both high and low conditions), steam pressure; water level supervisory signal initiating device; water temperature supervisory; and room temperature supervisory. EC Low Documentation of maintenance, testing, and inspection activities for EC , EPs 1 20, 25 (including fire alarm and fire protection systems) includes the following: - Name of the activity - Date of the activity - Inventory of devices, equipment, or other items - Required frequency of the activity - Name and contact information, including affiliation, of the person who performed the activity - NFPA standard(s) referenced for the activity - Results of the activity Note: For additional guidance on documenting activities, see NFPA : 4.3; 4.4; NFPA : ; ; ; Rolling fire door inspections did not have correct NFPA standard reference. Corrected onsite prior to surveyor's departure. EC Low Pattern Documentation of maintenance, testing, and inspection activities for EC , EPs 1 20, 25 (including fire alarm and fire protection systems) includes the following: - Name of the activity - Date of the activity - Inventory of devices, equipment, or other items - Required frequency of the activity - Name and contact information, including affiliation, of the person who performed the activity - NFPA standard(s) referenced for the activity - Results of the activity Note: For additional guidance on documenting activities, see NFPA : 4.3; 4.4; NFPA : ; ; ; The wrong NFPA edition, 1999, was documented on testing of duct, heat, smoke detectors, and manual fire alarm boxes, notification devices (audible & visual), and door-releasing devices, and smoke detection shutdown devices for HVAC for 2017 testing. This has already been corrected for 2018 testing. EC Low For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains a written inventory of all medical equipment. 1.) Aneroid sphygmomanometers not listed in mdeical equipment inventory. Corrected onsite prior to surveyor's departure (d)(2) Organization: Johnston Memorial Hospital 4 of 14 Preliminary Report: Posted 3/9/2018

5 EC Moderate Pattern EC Low The hospital inspects, tests, and maintains non-high-risk equipment identified 1.) Staff unable to demonstrate following MIFU for cleaning hydrocollator, on the medical equipment inventory. These activities are documented. hotpack covers, or the paraffin. Note: Scheduled maintenance activities for non-high-risk medical equipment in 2.) Digital thermometers expired. an alternative equipment maintenance (AEM) program inventory must have a 3.) Observed three temporal thermometers with cracked cases. They 100% completion rate. AEM frequency is determined by the hospital s AEM were all immediately removed from service. program. 4.) Hydrocollator was drained and cleaned once a month. The manufacturer's recommendation is to drain and clean the hydrocollator twice monthly. The hospital conducts performance testing of and maintains all sterilizers. These activities are documented. (See also IC , EP 2) Sterilizer was scheduled to be inspected on a quarterly basis. The last two inspections did not meet the 3 months +/- 10 days requirement (d)(2) (d)(2) EC Moderate Pattern EC Low The hospital designs and installs utility systems according to National Fire Protection Association codes to meet patient care and operational needs. The hospital labels utility system controls to facilitate partial or complete emergency shutdowns. Note 1: Examples of utility system controls that should be labeled are utility source valves, utility system main switches and valves, and individual circuits in an electrical distribution panel. Note 2: For example, the fire alarm system s circuit is clearly labeled as Fire Alarm Circuit; the disconnect method (that is, the circuit breaker) is marked in red; and access is restricted to authorized personnel. Information regarding the dedicated branch circuit for the fire alarm panel is located in the control unit. For additional guidance, see NFPA : 18/ ; ; NFPA : ) No nurse call devices in 7 patient bathrooms (a) 1.) The electrical breaker that powers the main fire alarm panel was not labeled in red at the time of survey. 2.) 1str floor electrical room, electrical panel # 1- EQL2 - Breaker # 19 was not labeled. Note- this finding was corrected during the survey. 3.) OR Panel was not labeled to identify the breakers and the areas served. Panel was correctly labeled prior to the completion of the survey. 4.) Breaker panel directories non compliant. 3 breakers on and not labeled. 5.) Panel P1-1 Directory did not match breaker layout (a) EC Moderate The hospital labels utility system controls to facilitate partial or complete 1.) Observed a LIM circuit breaker panel that had a blank panel schedule. emergency shutdowns. Note 1: Examples of utility system controls that should This was corrected during the survey. be labeled are utility source valves, utility system main switches and valves, and individual circuits in an electrical distribution panel. Note 2: For example, the fire alarm system s circuit is clearly labeled as Fire Alarm Circuit; the disconnect method (that is, the circuit breaker) is marked in red; and access is restricted to authorized personnel. Information regarding the dedicated branch circuit for the fire alarm panel is located in the control unit. For additional guidance, see NFPA : 18/ ; ; NFPA : (a) Organization: Johnston Memorial Hospital 5 of 14 Preliminary Report: Posted 3/9/2018

6 EC Moderate In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity. Note: For more information about areas designed for control of airborne contaminants, the basis for design compliance is the Guidelines for Design and Construction of Health Care Facilities, based on the edition used at the time of design (if available). 1). In Recovery, a room was being used to store sterilized wrapped trays. Temperature and humidity were not being monitored in the space. 2.) OR area, Clean OR equipment storage rooms located across from the ORs - The air flow for rooms 2213Q and 2214Q were negative to the hall, with air flowing from the hall into the clean storage room. The air flow should be positive, flowing from the room into the hall. Note- this finding was corrected during the survey and the correct air flows were verified by this surveyor. 3.) The following rooms did not have the appropriate pressure relationships: Soiled Utility Room 1534 the pressure was measured positive in relation to the clean side of operations rather than the required negative pressure to the clean side of operations, Sterile Supply Room 1527 the pressure was measured negative in relation to the clean side of operations rather than the required negative pressure to the clean side of operations. issues have been corrected prior to the completion of the survey. 4.) In sterile processing, observed the room pressure was negative to the corridor rather than positive. This was corrected during the survey EC Low Power strips in a patient care vicinity are only used for components of movable electrical equipment used for patient care that have been assembled by qualified personnel. These power strips meet UL 1363A or UL Power strips used outside of a patient care vicinity, but within the patient care room, meet UL In non patient care rooms, power strips meet other UL standards. (For full text, refer to NFPA : ; ; NFPA : 400-8; 590.3(D); Tentative Interim Amendment (TIA) 12-5) 1). A power strip in use inside the Endoscopy Procedure Room patient care vicinity was not UL 1363A or UL ) In space D-30, four power strips were observed plugged into each other (daily chained). 3). A refrigerator, microwave, toaster, and coffee maker were plugged into a power strip. The power strip was warm to the touch without the toaster and coffee maker in use EC Low Extension cords are not used as a substitute for fixed wiring in a building. 1)..An extension cord was being permanently used in OR 4 to power the Extension cords used temporarily are removed immediately upon completion surgery table. An extension cord was being permanently used in the MRI of the intended purpose. (For full text, refer to NFPA : ; ; Computer Room. Observed in Surveyor review but corrected onsite. NFPA : 400-8; 590.3(D); Tentative Interim Amendment (TIA) 12-5) EC Low The hospital provides emergency power within 10 seconds for the following: Emergency lighting at emergency generator locations. The hospital s emergency power system (EPS) has a remote manual stop station (with identifying label) to prevent inadvertent or unintentional operation. A remote annunciator (powered by storage battery) is located outside the EPS location. Note: For guidance in establishing a reliable emergency power system (that is, an essential electrical distribution system), refer to NFPA : ; ; ; NFPA : ; ) Remote manual stop station for external generator was attached the N/A outside weatherproof enclosure. NFPA 110 (2010) requires it to be located external to the generator. ILSM developed. N/A Organization: Johnston Memorial Hospital 6 of 14 Preliminary Report: Posted 3/9/2018

7 EC Moderate The hospital inspects, tests, and maintains the following: Infection control utility system components on the inventory. The completion date and the results of the activities are documented. Note 1: Required activities and associated frequencies for maintaining, inspecting, and testing of utility systems components completed in accordance with manufacturers recommendations must have a 100% completion rate. Note 2: Scheduled maintenance activities for infection control utility systems components in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate. 1.) In 16 of 90 Dish temperatures, were recorded in the month of November 2017, where the rinse temperature did not meet the minimum of 180 degrees. The kitchen manager stated that they did call the manufacturer and have them to make adjustments, however this was not documented. The staff also stated that they run chemical test strips periodically, however they did not keep the strips or document this procedure. The hospital began using a new form and procedure to insure the temperatures were maintained properly during the survey. 2.) Kitchen, In reviewing the dish machine temperature log, it was noted that on 2/20/18 the dish machine final rinse temperature was only 173 degrees. Final rinse should be 180 degrees to insure proper sanitation of the dishes. The was no record of the problem being reported, corrective actions taken, or retesting of the machine (d)(2) EC Low The hospital inspects, tests, and maintains the following: Nonhigh-risk utility 1.) There was an open electrical junction box located in the electrical room (d)(2) system components on the inventory. The completion date and the results of labeled the activities are documented. 2.) It was observed when evaluating the medication refrigerator on the IVH Note: Scheduled maintenance activities for non-high-risk utility systems unit, there was significant buildup of ice in and around the freezer components in an alternative equipment maintenance (AEM) program compartment. The freezer door could not be opened as a result of the ice inventory must have a 100% completion rate. AEM frequency is determined by buildup. the hospital AEM program. 3.) In OR2 the medical gas panel was blocked. It is important to note that the obstruction was removed from the front of the panel prior to the completion of the survey. 4.) It was noted above the fire/smoke door that there was an uncovered electrical junction box in the ceiling. It is important to note that junction box was covered prior to the completion of the survey. 5.) Electrical panel blocked by a cart. Corrected immediately. 6.) FDC obstructed by a bush. Bush removed prior to the completion of the survey. 7.) Above ceiling by door xx, observed an electrical junction box with no cover. This was corrected during the survey. EC Low The hospital meets NFPA : Health Care Facilities Code requirements 1.) LS Branch Electrical panel E2-1 had circuits that were not dedicated to related to electrical systems and heating, ventilation, and air conditioning the Life Safety Branch as required by NFPA 99 (2012) (Blood (HVAC). (For full text, refer to NFPA : Chapters 6 and 9) Bank,Refrigerator, Pharmacy refrigerator and computers in Pharmacy) Note: For hospitals that use Joint Commission accreditation for deemed status Circuits to be relocated. purposes: The hospital meets the applicable provisions of the Health Care Facilities Code Tentative Interim Amendments (TIAs) 12-2 and EC Low At least monthly, the hospital performs a functional test of emergency lighting 1.) April 2017 and May 2017 monthly testing of the exit signs were systems and exit signs required for egress and task lighting for a minimum not conducted with the required inventory. duration of 30 seconds, along with a visual inspection of other exit signs. The test results and completion dates are documented. (For full text, refer to NFPA : 7.9.3; ; NFPA : ) Organization: Johnston Memorial Hospital 7 of 14 Preliminary Report: Posted 3/9/2018

8 EC Low The hospital makes main supply valves and area shutoff valves for piped 1.) Above the ceiling at the double doors labeled "Fire Zone 26" - The medical gas and vacuum systems accessible and clearly identifies what the medical gas piping for Oxygen, Medical air and Vacuum are not labeled valves control. Piping is labeled by stencil or as to the type of gas contained in each pipe. The pipe was observed for adhesive markers identifying the gas or vacuum system, including the name of over 20 feet in each direction. system or chemical symbol, color code (see NFPA 99-2.) In the nursery by the nursing station, observed an emergency gas 2012: Table ), and operating pressure if other than standard. Labels are shutoff valve blocked by a sink and counter. at intervals of 20 feet or less and are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. (For full text, refer to NFPA : 5.1.4; ; ; ; ; ; ) (d)(2) EC Low The hospital implements a policy on all cylinders within the hospital that includes the following: - Labeling, handling, and transporting (for example, in carts, attached to equipment, on racks) in accordance with NFPA : and Physically segregating full and empty cylinders from each other in order to assist staff in selecting the proper cylinder - Adaptors or conversion fittings are prohibited - Oxygen cylinders, containers, and associated equipment are protected from contamination, damage, and contact with oil and grease - Cylinders are kept away from heat and flammable materials and do not exceed a temperature of 130 F - Nitrous oxide and carbon dioxide cylinders do not reach temperatures lower than manufacturer recommendations or -20 F - Valve protection caps (if supplied) are secured in place when cylinder is not in use - Labeling empty cylinders - Prohibiting transfilling in any compartment with patient care (For full text, refer to NFPA : ; ; ; ) 1.) During the tour of the Pediatric ED it was observed that a full oxygen tank and an empty one were next to each other in the corridor without any FULL or EMPTY tags. 2.) OR area, Storage room there were 4 unlabeled oxygen tanks stored in the room. Note - this finding was corrected during the survey (d)(2) EC Low The hospital meets all other NFPA : Health Care Facilities Code 1). The medical air compressor system was being used in sterile requirements related to gas and vacuum systems and gas equipment. (For full processing for blowing out various pieces of medical equipment with a text, refer to NFPA : Chapters 5 and 11) flexible hose and air nozzle. Note: For hospitals that use Joint Commission accreditation for deemed status 2.) Emergency O2 Supply connection box did not have apprpriate purposes: The hospital meets the applicable provisions of the Health Care signage. Corrected prior to surveyor's departure. Facilities Code Tentative Interim Amendments (TIAs) 12-4 and ( C ) Organization: Johnston Memorial Hospital 8 of 14 Preliminary Report: Posted 3/9/2018

9 EC Moderate WideSpread Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. 1). During a tour of the Geropysch unit, it was observed that there were ligature risks in the patient rooms. Grab bars were noted in several patient (a) rooms that had not been replaced. The organization had replaced some grab bars but the others were on back order. Headwalls that contained O2 outlets, air outlets, etc were protruding from the wall which created a ligature risk. Overhead lights above the beds were a ligature risk. Gaps around the storage units attached to the walls in the patient rooms created a possible ligature risk in all the rooms. In the corridor, there were 6 door knobs that were not in view of the nurses desk and a grab bar on the Exit door in the corridor. The organization has a very good ligature risk assessment and mitigation plan and are actively replacing ligature risk in the unit. The mitigation plan for the risk assessment is one on one care for the patient who is at risk although the unit has not had any high risk patients. Mitigation plans are as follows: Headwall slope area above headwall Cages take down cages over smoke heads while on survey Door knobs (hall) tag team staff in the hallway to monitor the hallway until these can be corrected Fire door push bar and closure device tag team staff in the hallway to monitor the hallway until these can be corrected Wardrobes caulk area Lights take down light fixture and cap off until the ordered lights arrive Grab bars take down grab bars. New ligature resistant bars have been ordered. Tub spouts / lever product received; installation in process Drawer in room fasten the drawer closed EC High Widespread Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. 1). 10 BHU bathroom doors did not have top cut hinges presented a ligature risk and doors were able to be latched closed (a) 2.) Rm 419 and laundry rm had stained ceiling tiles. 3.) In ED ligature risks associated with towel dispenser, IV poles, & plastic bags in trash cans. 4.) Laundry rm had greater than 1/8" gap betwen ceiling tiles an grid. 5.) 11 beds on BHU were metal framed. 6.) Bed on BHU had side rails. 7.) Sleep lab had 2 staine tiles in sleep study room 2. Fixed on site. Organization: Johnston Memorial Hospital 9 of 14 Preliminary Report: Posted 3/9/2018

10 EC Low Pattern Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. 1). It was observed when evaluating the patient shower on the IVH unit, the emergency cord near the shower was hung on the pull bar and was 2 feet from the floor. 2.) In 1 of 1 unit visited, it was observed that all of the beds on this unit were hospital beds and not ligature resistant. 3.) Patients on this particular unit are not medically required to have hospital beds. The HCO removed all the beds on the unit before the departure of the surveyors. 4.) Observed plastic bags were in some parts of the units, at the nursing station and in the linen hamper bag; the HCO removed and replaced all the plastic bags from the unit before the departure of the surveyors. 5.) Observed side rails with holes that can create a ligature risk for the patients, on both side of the unit hallway, as well as the far back wall closer to the exit door. The HCO removed all of the rails before the departure of the surveyors. All ligature risks were completed prior to the end of the survey. The organization had completed a risk assessment and a mitigation plan and all their high risk patients were one on one for any of the Behavioral Health patients. This was also confirmed by the LSC surveyor on site. 6.) 10 BHU bathroom doors did not have top cut hinges presented a ligature risk and doors were able to be latched closed. 7.) Rm xxx and laundry rm had stained ceiling tiles. 8.) ED ligature risks associated with towel dispenser, IV poles, & plastic bags in trash cans. 9.) Laundry rm had greater than 1/8" gap betwen ceiling tiles/grid. 10.) 11 beds on BHU were metal framed. 11.) Bed on BHU had side rails. 12.) Sleep lab had 2 staine tiles in sleep study room 2. Fixed on site. 13.) Emergency pull station cords were observed wrapped around a grab bars in the ED by exam rooms xx and xx. This was corrected during the survey (a) EC Low The hospital keeps furnishings and equipment safe and in good repair. 1.) ICU waiting room, observed a seat that had cracked upholstery that had split open. The seat was removed from service. 2.) An upholstered chair in a LDRP room was noted to have worn and chipped arms and the upholstery was worn and torn. This was observed by the CEO and Family Birthing nurse (a) EC Low Staff and licensed independent practitioners can describe or demonstrate actions to take in the event of an environment of care incident. In 1 out of 2 staff interviews, It was noted in an interview with staff in the kitchen that a staff member did not understand the actions needed to respond to a fire. The response given demonstrated a lack of knowledge on where to locate the fire extinguisher, how to activate the Ansul system, and when to activate the Ansul system. Organization: Johnston Memorial Hospital 10 of 14 Preliminary Report: Posted 3/9/2018

11 IC Moderate The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. 1.) It was observed when evaluating the ice machine dispenser in the IVH (c)(2) unit, was coated with white scaly buildup ). During a tour of the Emergency Department, the ice machine located in the nourishment room did not appear to have been cleaned. A finger sweep of the water side revealed gross black sediment. This was confirmed by the Risk Manager. 3.) Kitchen, dish room, pot sink - The Kitchen Manager was ask to verify that the chemical sanitation solution in the pot was at the correct concentration (200 to 300 ppm). When tested the concentration of the sanitation chemical was only 100 ppm. This problem was verified by the Kitchen Manager. 4.) Kitchen - At the time of survey, large amounts of soil /dirt and a buildup of chemical scale were noted on the floor along the wall and under the dish machine. A buildup of soil and dirt were also noted along the floor at the walls in other areas of the kitchen. This finding was verified by the Facilities Director 5.) In the Preop area across from the nursing station, observed an ice machine with a drain tray that was not draining and the tray was visibly soiled. This was corrected during the survey. IC Low The hospital implements infection prevention and control activities when doing the following: Cleaning and performing low-level disinfection of medical equipment, devices, and supplies. * Note: Low-level disinfection is used for items such as stethoscopes and blood glucose meters. Additional cleaning and disinfecting is required for medical equipment, devices, and supplies used by patients who are isolated as part of implementing transmission-based precautions. Footnote *: For further information regarding cleaning and performing low-level disinfection of medical equipment, devices, and supplies, refer to the website of the Centers for Disease Control and Prevention (CDC) at In the pre-surgery area, the ice machine was noted to have a prominent chemical residue in the tray. The nursing staff stated the machine was cleaned monthly LS Low The hospital maintains current and accurate drawings denoting features of fire safety and related square footage. Fire safety features include the following: - Areas of the building that are fully sprinklered (if the building is partially sprinklered) - Locations of all hazardous storage areas - Locations of all fire-rated barriers - Locations of all smokerated barriers - Sleeping and non-sleeping suite boundaries, including the size of the identified suites - Locations of designated smoke compartments - Locations of chutes and shafts - Any approved equivalencies or waivers 1st floor, above the ceiling at the double smoke doors labeled "Zone 1E - The life Safety drawings show the wall as a smoke wall. The smoke wall above the ceiling is incorrectly labeled as a 2 hour fire wall. N/A N/A LS Low The hospital does not remove or minimize an existing life safety feature when OR suite boundary door had lower latches removed. Corrected on site such feature is a requirement for new construction. Existing life safety features, prior to surveyor's departure. if not required by the Life Safety Code, can be either maintained or removed. (For full text, refer to NFPA : ; ) N/A N/A Organization: Johnston Memorial Hospital 11 of 14 Preliminary Report: Posted 3/9/2018

12 LS Moderate Fire-rated doors within walls and floors have functioning hardware, including 1.) The set of 1 hour rated fire doors labeled #7000 would not properly positive latching devices and self-closing or automatic-closing devices. Gaps latch upon release. This finding was observed during survey activity, but between meeting edges of door corrected onsite prior to the surveyors departure. pairs are no more than 1/8 of an inch wide, and undercuts are no larger than 3/4 of an inch. Fire-rated doors within walls do not have unapproved protective plates greater than 16 inches from the bottom of the door. Blocking or wedging open fire-rated doors is prohibited. (For full text, refer to NFPA : ; NFPA : ; ; ; 6.4.5) LS Low Fire-rated doors within walls and floors have functioning hardware, including positive latching devices and self-closing or automatic-closing devices (either kept closed or activated by release device complying with NFPA : ). Gaps between meeting edges of door pairs are no more than 1). The double doors at the rear of Materials Management would not selfclose when tested. The door coordinator was malfunctioning. The doors were in a two-hour rated exit passageway wall assembly. This finding was observed during survey activity, but corrected onsite prior to the surveyor's 1/8 of an inch wide, and undercuts are no larger than 3/4 of an inch. Fire-rated departure. doors within walls do not have unapproved protective plates greater than 16 inches from 2.) 2hr fire door on 1st Flr by vending machines did not latch into the floor. Corrected prior to surveyor's departure. the bottom of the door. Blocking or wedging open fire-rated doors is prohibited. (For full text, refer to NFPA : ; NFPA : ; ; ; 6.4.5; ) LS Low Exits discharge to the outside at grade level or through an approved exit passageway that is continuous and provides a level walking surface. The exit discharge is a hard-packed, all-weather travel surface that is free from obstructions and terminates at a public way or at an exterior exit discharge. (For full text, refer to NFPA : 18/19.2.7; 7.1.7; ; 7.2.6; 7.7.2) The exit discharge by room 127 was not a hardpacked, all-weather travel surface.the surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization s ILSM policy: x(ep-15) LS Low LS Low Signs reading "NO EXIT" are posted on any door, passage, or stairway that is neither an exit nor an access to an exit but may be mistaken for an exit. (For full text, refer to NFPA : 18/ ; ) All existing hazardous areas have doors that are self-closing or automaticclosing. These areas are protected by either a fire barrier with one-hour fireresistive rating or an approved electrically supervised automatic sprinkler system. Hazardous areas include, but are not limited to, boiler and fuel-fired heater rooms, central/bulk laundries larger than 100 square feet, paint shops, repair shops, soiled linen rooms, trash collection rooms with containers exceeding 64 gallons, laboratories employing flammable or combustible materials deemed less than a severe hazard, and storage rooms greater than 50 square feet used for storage of equipment and combustible supplies. (For full text, refer to NFPA : ; ; ; ) 1.) The patio doors did not have a No Exit sign in the following locations: the fourth floor and the third floor. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. 1.) Clean supply rm had a damaged ceiling tile causing a gap greater than (b)(1)(ii) 1/8 inch 2.) Soiled utility room door in PACU did not latch. 3.) Pharmacy storeroom had a gap in the ceiling greater than 1/8" 4.) Gift shop door had an undercut greater than 3/4" Corrected onsite prior to surveyor's departure. LS Low Widespread Note: For hospitals that use Joint Commission accreditation for deemed status purposes: Doors to rooms containing flammable or combustible materials are provided with positive latching hardware. Roller latches are prohibited on such doors. In 8 of 8 Corridor door latches, on the 4th floor would not properly latch upon testing. This area was listed as a suite at one time in the past, and had been reclassified. These 8 patient room doors were of a sliding type, however the latching systems would not latch at the time of survey (b)(1)(ii) Organization: Johnston Memorial Hospital 12 of 14 Preliminary Report: Posted 3/9/2018

13 LS Low Pattern In existing buildings, all corridor doors are constructed to resist the passage of 1.) Corridor doors did not latch in the following locations: room 3311, smoke and constructed of 1 3/4-inch or thicker solid bonded wood core or 3308, 3307, Door 1 in the Cath Lab, and Door 2 in the Cath lab. constructed of material that resists fire for not less than 20 minutes, and the 2.) It was noted the fire door did not latch at the D Stairwell 5, 2nd floor. doors do not have ventilating louvers or transfer grills (with the exception of 3.) Patient room 411 did not latch. Corrected onsite prior to surveyor's bathrooms, toilets, and sink closets that do not contain flammable or departure. combustible materials). Positive latching hardware is required. Roller latches are prohibited. (For full text, refer to NFPA : ; ; ) Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: Powered corridor doors are equipped with positive latching hardware unless the organization can verify that this equipment is not an option provided by the door manufacturer. In instances where positive latching hardware is not an available option provided by the manufacturer, the device used must be capable of keeping the door fully closed when a force of 5 lbf is applied at the latch edge and in any direction to a sliding or folding door, whether or not power is applied in accordance with NFPA : Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials are not required to have a device capable of keeping the door fully closed if a force of 5 lbf is applied at the latch edge. In these cases, roller latches are permissible (b)(1)(ii) LS Low Smoke barriers extend from the floor slab to the floor or roof slab above, through any concealed spaces (such as those above suspended ceilings and interstitial spaces), and extend continuously from exterior wall to exterior wall. All penetrations are properly sealed. (For full text, refer to NFPA : 18/ ; 8.2.3; 8.5.2; 8.5.6; 8.7) Note: Polyurethane expanding foam is not an accepted fire-rated material for this purpose. 1.) Above fire/smoke door # in the one hour fire/smoke partition penetrations were present in the following situations: Two yellow pipes penetrated the barrier with no fire caulk present, One copper line penetrating the wall contained a gap of greater than 1/8 inch, Two blue pipes penetrated the barrier with no fire caulk This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. 2.) Corridor by 2nd FLoor lab had >1/8 gap. Corridor walls not continuous to the deck above. Corrected onsite prior to surveyor's departure. 3.) Above ceiling by door xxx, observed a penetration through smoke barrier.this finding was observed during survey activity, but corrected onsite prior to the surveyor s departure. The corrective action taken needs to be included in the organization s Evidence of s Compliance submission LS Low Doors in smoke barriers are self-closing or automatic-closing, constructed of 1 3/4-inch or thicker solid bonded wood core or constructed to resist fire for not less than 20 minutes, and fitted to resist the passage of smoke. The gap between meeting edges of door pairs is no wider than 1/8 of an inch. In new buildings, undercuts are no larger than 3/4 of an inch, and doors in a means of egress swing in the opposite direction. (For full text, refer to NFPA : ; 18/ ; ; NFPA : ; ) 1.) The set of smoke barrier doors labeled 023 were equipped with latching hardware, but would not properly latch upon release. This finding was observed during survey activity, but corrected onsite prior to the surveyors departure. 2) At the one hour fire/smoke door # the gap at the undercut of the door is greater than 3/4 inch. 3) At one hour fire/smoke door # the gap at the meeting edge of the door is greater than 1/8 inch.this finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. Organization: Johnston Memorial Hospital 13 of 14 Preliminary Report: Posted 3/9/2018

14 LS Low LS Low The hospital meets all other Life Safety Code fire alarm requirements related to NFPA : 18/ Piping for approved automatic sprinkler systems is not used to support any other item. (For full text, refer to NFPA : ) 1.) 3rd floor, ICU - The fire alarm bull box was blocked by a paper recycling container. 2.) BHU TM did not have key to perate fire alarm pull station. 1.) At the 2 hour fire barrier between ER and the Medical Plaza a fire alarm wire is draped across the sprinkler pipe.this finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. 2.) Conduit lashed to sprinkler pipe. Corrected onsite prior to the surveyor's departure. 3.) In Radiology by dressing room xx above the ceiling, observed an electronic box and a bundle of cables supported by the fire sprinkler piping.this finding was observed during survey activity, but corrected onsite prior to the surveyor s departure. The corrective action taken needs to be included in the organization s Evidence of s Compliance submission. LS Low The hospital meets all other Life Safety Code automatic extinguishing requirements related to NFPA : 18/ ). On Level 3, a ceiling tile approximately 3 inches by 3 inches was missing. The room was equipped with sprinkler protection only. Observed in Surveyor review but corrected onsite. 2.) On Level 1 in the MRI Computer Room, several ceiling tiles were missing. The room was equipped with sprinkler protection only. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Increase surveillance (EP-8) 3. 2 patient rooms had gaps in ceilign greater than 1/8" Rm 315 and CT room. Corrected onsite prior to the surveyor's departure. LS Moderate The hospital meets all other Life Safety Code automatic extinguishing requirements related to NFPA : 18/ In the kitchen above the fryer and grill, observed two separate gaps in the baffles witch would allow grease to enter the hood ventilation system.this finding was observed during survey activity, but corrected onsite prior to the surveyor s departure. The corrective action taken needs to be included in the organization s Evidence of s Compliance submission LS Low Soiled linen and trash receptacles larger than 32 gallons are stored in a room 1). A regular trash container > 32 gallons was in use inside the Surgery protected as a hazardous area. (For full text, refer to NFPA 101- Staff Lounge. This finding was observed during survey activity, but 2012: 18/ ) Note: Containers that are 96 gallons or less and are labeled corrected onsite prior to the surveyor's departure. and listed as meeting the requirements of FM Approval 6921 (or equivalent) and are used solely for recycling clean waste (including patient records awaiting destruction) are permitted in an unprotected area. Those containers that are greater than 96 gallons are stored in a hazardous storage area. Organization: Johnston Memorial Hospital 14 of 14 Preliminary Report: Posted 3/9/2018