Faulkton Area Medical Center

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 25107 Based on observation, testing, interview, and policy review the provider failed to maintain one of two blanket warmers at a safe temperature in accordance with their policy. Findings include: 1. Observation on 8/6/24 at 9:00 a.m. in emergency room one the blanket warmer read 160 degrees Fahrenheit (F) on the digital display. Observation and testing on 8/6/24 at 1:57 p.m. of the temperatures in the blanket warmer in emergency room one revealed: *The digital display showed 160 degrees Fahrenheit (F). *Testing of the temperature by placing a thermometer between two blankets revealed the temperature was 150 degrees F. A request for a policy regarding the blanket warmer temperature was made to chief executive officer (CEO) A. On 8/6/24 at 3:00 p.m. CEO A provided the “Warming Blanket” policy. She stated there was not a policy that directly addressed the blanket warmers, and this policy was the only one they had that referenced the temperature of blankets. Review of the provider’s warming blanket policy dated October 30, 2019 revealed: *The purpose of the policy was to treat a patient with hypothermia. *The procedure identified the steps how to apply a Bair Hugger warming blanket and a cotton blanket single thickness over the top of the Bair Hugger blanket and to track temperatures to treat hypothermia. *Step seven of the procedure indicated staff “May initiate use of warming lights, warmed IV (intravenous) fluids [kept in warmer at 103 degrees Fahrenheit], warmed blankets [kept in warmer at 130 degrees Fahrenheit], or increase room temp as appropriate and as ordered.” Observation and interview on 8/6/24 at 3:44 p.m. with CEO A and DON B in emergency rooms one and two revealed: *The blanket warming cabinet in emergency room two was set at 130 degrees F. It also had a fluid warmer that was set at 103 degrees F. *DON B stated they tracked the temperatures of the fluids but not the blankets. *They did not know why the blanket warmer in emergency room one was set at 160 degrees F. *They agreed the blanket warmer in emergency room one should not have exceeded 130 degrees F. *DON B then set the temperature of the blanket warmer to 130 degrees F. Observation at 8:10 a.m. on 8/7/24 revealed the digital display for the blanket warmer in emergency room one read 130 degrees F.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 40506 Based on record review and interview, the provider failed to conduct the required every six-month inspection of the facility’s cooking ductwork exhaust system for the range hood for the calendar year 2023. Findings include: 1. Record review revealed there was no documentation the kitchen hood exhaust ductwork had been inspected for cleanliness and grease build-up in 2023. Interview with the maintenance supervisor at 1:55 p.m. on 8/7/24 revealed he was unaware of the ductwork inspection requirements. The deficiency affected the requirements for the kitchen range hood exhaust system.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 40506 Based on observation and record review, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (gauge replacement and the 5-year internal pipe inspection). Findings include: 1. Observation at 10:05 a.m. on 8/7/24 revealed the gauges for the sprinkler system had last been replaced 5/29/18. Gauges are required to be calibrated or replaced every five years. Record review at 2:15 p.m. on 8/7/24 revealed the contractor for sprinkler maintenance had noted the deficiency in the 2023 annual inspection, but had not corrected the deficiency. 2. Observation at 10:08 a.m. on 8/7/24 revealed there was no tag available for a five-year internal pipe inspection. Record review at 2:15 p.m. on 8/7/24 revealed the contractor for sprinkler maintenance had noted the deficiency in the 2023 annual inspection, but had not corrected the deficiency. Interview with the maintenance supervisor at the time of the observation confirmed that condition. Failure to continuously maintain the automatic sprinkler system as required increases the risk of death or injury due to fire. The deficiencies affected two of numerous required maintenance items for the automatic sprinkler system.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 40506 Based on observation and interview, the facility failed to protect medical gas storage as required. Forty-one H-cylinders (10,004 cubic feet) were stored in a hazardous room with no functioning exhaust available. Findings include: 1. Observation on 8/7/24 at 11:30 a.m. revealed the oxygen storage room for the piped medical gas system held 41 H-cylinders or 10,004 cubic feet of oxygen. A maximum of 3000 cubic feet of gas storage was allowed in a room without continuous exhaust. Interview with the maintenance supervisor at the time of observation revealed he was not aware the exhaust system was not working. Further investigation by the maintenance supervisor revealed the exhaust fan motor was burned out and an order for a replacement motor was placed. The deficiency affected one of three smoke compartments.”