A series of citations for life-safety deficiencies is threatening the accreditation of a rural Colorado hospital.
For 40-bed Prowers Medical Center in Lamar, the outcome of a survey done Aug. 9 to 11 by the Joint Commission on Accreditation of Healthcare Organizations was a matter of too many gaps-in standards interpretation, in documentation of inspections, in continuous outside monitoring, even the clearance of some doors.
For the JCAHO, it added up to conditions that "posed a threat to patient and public safety," an on-the-spot surveyor judgment that triggered a fast-track decision to deny accreditation on Aug. 16.
In announcing the decision last week, the JCAHO would say only that the citations involved plant, technology and safety issues. "While it may appear that those issues are not related to patient care, they are in fact related to the safety of every patient in the hospital," said JCAHO spokeswoman Alice Brown.
At Prowers, the main problems involved preparedness for a fire, both internally and in the way the hospital was monitored by outside sources, said Earl Steinhoff, chief executive officer.
Instead of hiring an outside monitoring agency, the small hospital relies on the local fire department to monitor the alarm that goes off in the fire station when the hospital alarm or sprinkler systems are activated, Mr. Steinhoff said.
When the fire department responds to fire calls, backup volunteers cover the station, but it takes them five to 10 minutes to get there. A surveyor concluded that the hospital is "disconnected from the fire department" based on that routine, Mr. Steinhoff said.
He also said a surveyor cited the fire-drill routine when an alarm was not pulled during a drill conducted for the JCAHO team. The surveyor asked an employee about it, and the employee responded that orders were not to pull the alarm. The surveyor mistakenly believed the employee was referring to response to an actual fire, while the employee meant he wasn't supposed to pull it during a drill, according to Mr. Steinhoff.
The hospital also was cited because employees had never internally tested the alarm system that was installed in 1981. There also was no documentation that the sprinkler system had been checked. Mr. Steinhoff said monitoring and testing are done by an outside firm.
Other problems included doors that either did not close properly because of sealing around them or had gaps around them that were wider than allowed, he said. The hospital had an addition built in 1991, and settling and minor construction flaws may have had something to do with those problems, which were quickly corrected, he said.
In the older part of the hospital, the ventilation system also did not shut off as required when an alarm was pulled.
The hospital plans to appeal the so-called "adverse accreditation decision" on grounds that strict interpretations of standards made the situation seem a lot worse than it was.
"In no place in this hospital are you more than 100 feet away from an exit," Mr. Steinhoff said. The facility is on one floor, with no stairs, and potential fire sources such as the boiler and laundry rooms are separated from the main structure, he said.