Bibb Medical Center

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 46290 Based on observations, hospital policy, and interviews during a hospital tour with hospital staff and the Life Safety Code surveyor, it was determined: 1. The hospital was not constructed, arranged and maintained to ensure patient safety. 2. Expired supplies were not available for patient use. This had the potential to affect all patients served by this hospital. Findings include: Refer to Life Safety Code violations, and A 724 for findings.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 41624 Based on review of Medical Records (MR), hospital policies, Alabama Board of Nursing Administrative Code Standards of Nursing Practice, and interviews with staff it was determined the hospital failed to ensure: 1. An initial assessment for the need of PRN (as needed) medication and/or a follow up assessment was documented after the PRN medication was administered. 2. The staff documented turning and repositioning of patients every two hours. 3. The staff measured and documented the measurements of a new Stage two pressure ulcer. This affected two of five MR’s reviewed that received PRN medications, including Patient Identifier (PI) # 9 and PI # 3, and one of one MRs reviewed for patients with pressure ulcers, including PI # 3, and had the potential to negatively affect all patients receiving care at this hospital. Findings include: Hospital Policy: PRN Medications Policy Number: None Revised Date: None Purpose: The registered nurse continually assesses the patient’s response to scheduled medication(s) and assesses the need for additional medication. Administration of PRN medication will be documented on the Medication Administration Record (MAR). Hospital Policy: Medication - Dispensing and Administering Drugs Related to Nursing Policy Number: None Revised Date: 12/3/18 ...16. Document effects of all medications Alabama Board of Nursing Administrative Code Chapter 610-X-6 Standards of Nursing Practice 610-X-6-.07 Standards For Medication Administration And Safety. ...(2) The licensed nurse shall exercise decision-making skills when administering medications, to include but not limited to: (a) Whether medications should be administered. (b) Assessment of patient’s health status and complaint prior to and after administering medications, including PRN medications. Hospital Policy: Decubitus Ulcers: Management and Care. Policy Number: None Listed Revised Date: 2/19 Policy Statement: 1. All patients with impaired mobility will be turned and repositioned and inspected for signs of pressure or skin breakdown every two (2) hours by nursing personnel. ...Charting: 1. Date, time and activities performed. 2. Observations of skin condition and measurements of wound (on) admission and weekly... 1. PI # 9 was admitted for observation on 6/6/24 with a diagnosis of Chronic Obstructive Pulmonary Disease. Review of the 6/6/24 intravenous (IV) Medication Orders revealed a physician order for Promethazine IV 12.5 milligrams (mg) every six hours PRN for nausea and vomiting (N/V) in 50 milliliters (ml) 0.9 % (percent) sodium chloride (0.25 mg per ml), 100 ml per hr (hour) for 30 minutes. Review of the 6/7/24 Medication Orders revealed a physician order for Acetaminophen Oral 650 mg every six hours PRN pain/fever. Review of the MAR for 6/6/24 to 6/7/24 revealed the following PRN medications were administered with no documentation of PI # 9’s complaint prior to administration: a. Acetaminophen 650 mg on 6/6/24 at 1:40 PM. b. Promethazine 12.5 mg on 6/7/24 at 1:40 PM. Review of the MAR for 6/6/24 to 6/7/24 revealed the following PRN medications were administered with no documentation of the effectiveness of the medication: a. Acetaminophen 650 mg on 6/7/24 at 6:50 AM and 1:40 PM. b. Promethazine 12.5 mg on 6/7/24 at 1:40 PM. An interview was conducted on 8/1/24 at 3:53 PM with Employee Identifier (EI) # 5, Infection Preventionist, who confirmed there was no documentation of the assessment for the need of the PRN medications prior to administration nor of the effectiveness of the PRN medications after administration. 41623 2. PI # 3 was admitted to Swing Bed on 7/18/24 with diagnoses including Acute Urinary Tract Infection, Hypertensive Disorder, and Physical Deconditioning. Review of the physician’s orders dated 7/18/24 revealed orders for Acetaminophen 650 mg orally every six hours as needed for pain and fever. Review of the nursing documentation dated 7/19/24 at 12:36 PM revealed the nurse documented PI # 3 complained of “body aches all over,” and Tylenol (Acetaminophen) 650 mg was given. There was no documentation of the patient’s level of pain nor the effectiveness of the pain medication. Review of the medication profile dated 7/20/24 at 4:20 PM revealed the nurse documented Acetaminophen 650 mg was given. There was no documentation of the location or the level of pain and the effectiveness of the pain medication. Further review of PI # 3’s MR revealed on 7/17/24 at 4:30 AM the RN documented the presence of a 4.5 centimeter (cm) by 5.5 cm Deep Tissue Injury (DTI) to the right trochanter, a 1.5 cm x 2.0 cm intact blister to the right trochanter, and a DTI to the outer ear lobe. There was no documentation of a skin assessment upon admission to the swing bed. Review of the physician’s orders dated 7/18/24 revealed orders to turn patient every two hours and float heels. Review of the nursing documentation dated 7/18/24 at 1:30 PM revealed the nurse documented the presence of a 4 cm by 3 cm DTI to the right trochanter. Review of the nursing documentation dated 7/19/24 at 5:17 PM, 7/20/24 at 6:29 PM, and 7/21/24 at 6:25 PM revealed the nurse documented PI # 3 was turned and repositioned. There was no documentation what position PI # 3 was turned to, and no documentation PI # 3 was repositioned every two hours. Review of the nursing documentation dated 7/22/24 at 6:32 PM revealed the nurse documented the presence of a Stage two pressure ulcer to the right hip. There was no documentation of the wound measurements of the new Stage two pressure ulcer. An interview was conducted on 8/1/24 at 3:05 PM with EI # 5 who confirmed the staff failed to document the level of pain, and the effectiveness of the pain medication after administration. EI # 5 further confirmed staff failed to obtain wound measurements per hospital policy and failed to document the position change every two hours.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 49603 Based on review of medical records (MR) and interviews, it was determined the hospital failed to ensure the staff developed and updated nursing care plans with goals and treatments. This affected one of one respite records and one of two swing bed records reviewed, including Patient Identifiers (PI) # 16, PI # 3, PI # 11, and had the potential to affect all patients receiving care at this hospital. Findings include: Hospital Policy: Respite Care Policy Number: None Effective Date: 10/1/16 ...Procedure: ...4. Hospital shall provide the following services to Patients in accordance with all applicable federal and state laws and other applicable professional standards. a. ...Patient’s needs (are) furnished in accordance with the Plan of Care, or as otherwise may be required by state law... 1. PI # 16 was admitted on 5/21/24, with a diagnosis of Cellulitis of Left Upper Limb and Sepsis. Review of PI # 16’s MR revealed no documentation of an inpatient nursing care plan. An Interview was conducted on 8/1/24 at 3:12 PM with Employee Identifier (EI) # 5, Registered Nurse (RN), Infection Preventist, and EI # 10, Director of Respiratory, who confirmed no inpatient nursing care plan was completed. 41623 2. PI # 3 was admitted to Swing Bed on 7/18/24 with diagnoses including Acute Urinary Tract Infection, Hypertensive Disorder, and Physical Deconditioning. Review of the physician’s orders dated 7/18/24 at 1:22 PM revealed orders to turn and reposition every two hours and float heels. Review of the nursing documentation dated 7/18/24 at 1:30 PM revealed the nurse documented the presence of a Deep Tissue Injury (DTI) to the right trochanter measuring 4 centimeters by 3 centimeters. Review of the Care Plans dated 7/18/24 revealed documentation of care planning for fall risk and pain. There was no documentation a plan of care was developed for the prevention and care of pressure ulcers. Review of the nursing documentation dated 7/22/24 at 6:32 AM revealed the nurse documented the presence of a Stage two pressure ulcer to the right hip. An interview was conducted on 8/1/24 at 3:05 PM with EI # 5, who confirmed the care plan was not updated to include changes in the patient’s needs. 3. PI # 11 was admitted to Respite Care on 6/26/23 with diagnoses including Dementia, Hypertension, Hyperlipidemia, Hypothyroidism, and Insomnia. Review of the MR revealed no documentaion a Care Plan was developed. An interview was conducted on 8/1/24 at 3:40 PM with EI # 2, RN, Utilization Review, who confirmed a Care Plan was not documented.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 46293 Based on observations, hospital policy and procedures, Centers for Disease Control (CDC) Frequently Asked Questions (FAQS) regarding Safe Practices for Medical Injections, Manufacturer’s Instruction for Use, Hospital Pharmacy Reference Table for Refrigerated Medications, and interviews, it was determined the hospital failed to ensure: 1. Opened multi-dose vials (MDV) in an immediate patient use area were dedicated for single patient use and discarded immediately after use. 2. Opened MDV were discarded within 28 days of opened date. 3. Anesthesia medications requiring refrigeration were dated when removed from refrigeration. 4. Expired medications and intravenous (IV) fluids were not available for patient use. 5. Opened single dose vials were not available for patient use. This had the potential to negatively affect all patients served by the hospital. Findings Include: Hospital Policy Description: Safe Injection Practices Policy Number: None Revised Date: None Purpose: Injected medicines are commonly used in healthcare settings for the prevention, diagnosis, and treatment of various illnesses. Unsafe injection practices put patients and healthcare providers at risk for infectious and non-infectious adverse events and have been associated with a wide variety of procedures and settings. This harm is preventable. Safe injection practices are part of Standards of Precautions and are aimed at maintaining basic levels of patient safety and provider protection. Policy: ...IV. Flushing ...b. If a MDV must be used, it is best practice to dedicate it for use on only one patient and then discard it... V. Medication Vials and Ampules: a. Always follow the manufacturer’s instructions for storage and use. b. Check the manufacturer’s expiration date on all medication vials prior to use. ...i. Use MDV for one patient whenever possible... j. Store and access multidose vials away from the immediate patient care environment... ...p. Label a MDV with a beyond-use-date (BUD) when first accessing it. The BUD after initially entering a MDV is 28 days. CDC FAQs regarding Safe Practices for Medical Injections ...2. MDV should be dedicated to a single patient whenever possible. If MDV must be used for more than one patient, they should be only kept and accessed in a dedicated medication preparation area (e.g. nurses station) away from immediate patient treatment areas... ...examples of immediate patient treatment areas include operating and procedure rooms, anesthesia and procedure carts and patient rooms or bays... Manufacturer’s Instructions For Use- Succinylcholine Chloride ...How Supplied/Storage and Handling Refrigeration of the undiluted Succinylcholine Chloride will assure full potency until expiration date... Store in refrigerator 2 degrees C (Centigrade) to 8 degrees C... Hospital Pharmacy Reference Table for Refrigerated Medications Table Number: None listed Revised Date: None listed ...A list of medications requiring refrigeration for long-term storage has been established. The room temperature stability of these medications has also been established... ...Succinycholine- 14 days Hospital Policy: Outdated Supplies and Drugs Related to: All Nursing Care Areas Revised Date: 12/10/18 Policy: At the first of each month, supply carts, medication room and crash carts are to be checked for outdated supplies and drugs. Outdated drugs are to be returned to the pharmacy and outdated supplies are to be destroyed and supplies re-ordered. 1. A tour of the Medical Surgical unit was conducted on 7/30/24 at 11:45 AM with Employee Identifier (EI) # 1, Registered Nurse (RN), Director of Nursing. The following IV fluids in the Medication Room and Supply Room were expired and available for patient use: - Ten 5 % Dextrose with 0.2 % Normal Saline 1000 milliliter (ml) bags with expiration date of 2/29/24. - Sixteen 5 % Dextrose 250 ml bags with an expiration date of 2/24. - One 5 % Dextrose 500 ml bag with an expiration date of 12/23. An interview was conducted on 7/30/24 at 11:45 AM with EI # 1 who confirmed the IV fluids were expired and available for patient use, and staff failed to discard, per policy. 2. An observation of medication administration by EI # 9, RN, was conducted on 7/30/24 at 11:50 AM. EI # 9 removed the cap from a 10 ml vial of furosemide 10 milligram (mg)/ml, withdrew 4 ml, and labeled the vial with the date and time opened and placed the vial back on the shelf for use. The opened single dose vial was available for use for other patients. An interview was conducted on 7/30/24 at 12:05 PM with EI # 9 who confirmed the furosemide vial was a single dose medication and staff failed to discard per policy. 3. A tour of the Emergency Department was conducted on 7/30/24 at 11:50 AM. The following supplies were found to be expired and available for patient use. Emergency Room 2: - Three 1000 ml bags of 5 percent (%) Dextrose with an expiration date of March 2024. - Two 1000 ml bags of 5% Dextrose/0.9% Normal Saline with an expiration date of May 2024. Trauma Room A: - Five 1000 ml bags of 5% Dextrose/0.9% Normal Saline with an expiration date of May 2024. - One 1000 ml bag of 20 milliequivalent (mEq) Potassium Chloride with an expiration date of May 2024. An interview was conducted on 7/30/24 at 12:09 PM with EI # 3, RN, who confirmed the medications were expired and available for patient use, and staff failed to discard per policy. 4. A tour of the Surgical Suites and Labor and Delivery (L&D) Unit was conducted on 7/30/24 at 12:03 PM, with EI # 5, Infection Preventionist. An inspection of the anesthesia cart in the C-section Suite revealed an opened 10 ml MDV of Oxytocin 10 units/ml available for patient use. EI # 5 confirmed at the time that the MDV was not dedicated to single patient use and discarded immediately after use, per policy. A further inspection of the anesthesia cart revealed an unopened 10 ml MDV of Succinylcholine Chloride with no out of refrigeration date on the label to know when it would expire in 14 days. EI # 5 confirmed there was no date written on the label when it had been removed from refrigeration, and staff failed to follow the manufacturer’s instructions for use. An inspection of the cabinet in the L&D Medication Room revealed a 10 ml MDV of Oxytocin 10 units/ml with a written opened date of 6/27/24 on the label. The expired MDV was four days past the 28 days allowed for a MDV after it has been opened. This date was confirmed by EI # 5 at the time of the observation, and further confirmed staff failed to discard the MDV per policy. 41623 49894”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 49894 Based on observations, review of hospital policy, and staff interviews, it was determined the facility failed to ensure expired supplies were not available for patient use. This had the potential to negatively affect all patients served by the hospital. Findings include: Hospital Policy: Outdated Supplies and Drugs Related to: All Nursing Care Areas Policy Number: None Revised Date: 12/10/18 Policy: At the first of each month, supply carts, medication room and crash carts are to be checked for outdated supplies... Outdated... supplies are to be destroyed and supplies re-ordered. 1. A tour of the Emergency Department was conducted on 7/30/24 at 11:50 AM. The following supplies were found to be expired and available for patient use: Emergency Room 2: - One box 18 inch Ethilon sutures, originally containing 12 sutures. There were eight sutures with an expiration date of 3/31/24 and one suture with the expiration date of 6/30/24. - One box 18 inch Ethicon Fast Absorbing Plain Gut sutures, originally containing 12 sutures. There were two sutures with the expiration date of 5/31/24. - One box of 18 inch Chromic Gut sutures, originally containing 12 sutures. There were 10 sutures with an expiration date of 4/24. An interview was conducted on 7/30/24 at 12:09 PM with Employee Identifier (EI) # 3, Registered Nurse (RN), who confirmed the supplies were expired and available for patient use. 41624 2. A tour of the Emergency Department was conducted on 7/30/24 at 11:59 AM. The following supplies were found to be expired and available for patient use. Trauma Bay B: - An opened box of Povidone Iodine swabsticks with 43 remaining in the box with an expiration date of 06/2024. EI # 3 confirmed the expired supplies at the time of the tour. 46293 3. A tour of the Surgical Suite and Labor and Delivery (L&D) Unit was conducted on 7/30/24 at 12:03 PM with EI # 5, Infection Preventionist. During the tour, the following supplies were found to be expired and available for patient use. Anesthesia Cart Cesarean Section (C-Section) Suite: - Forty Becton Dickinson (BD) 22 gauge (g) 1 1/2 inch (“) Precision Glide Needles with an expiration date of 11/30/23. - Two Medline Intravenous (IV) Start Kits with chloroprep applicator with an expiration date of 12/31/23. - Five BD Vacutainer Purple top tubes with an expiration date of 12/31/22. - One Pajunk Sonoblock 11 Facet S 20g x (by) 120 mm (millimeter) with an expiration date of 12/3/23. - Two Tuohy Epidural Needles 18g x 5” with an expiration date of 8/31/23. - Three Gerti Marx Spinal Needles with Introducer 22g x 90 mm/3.5” with an expiration date of 1/22. - Five Gerti Marx Spinal Needles with Introducer 22g x 90 mm/3.5” with an expiration date of 2/24. - One Rusch Teleflex DispoLED Disposable Laryngoscope Handle with an expiration date of 4/27/23. - One Brute Pro Solo Miller 1 Flex with an expiration date of 11/21. - One Brute Pro Solo Miller 00 Flex with an expiration date of 12/21. - One Brite Pro Solo Miller 0 Flex with an expiration date of 3/22. - Seven Cardinal Health Sterile Wooden Tongue Blades with an expiration date of 5/12/22. - One Cardinal Health Non-Conductive Suction Tubing with an expiration date of 7/1/24. - One Sun Med Bougie Introducer with an expiration date of 2/2/21. - One i-Gel Supraglottic Airway size 5 with an expiration date of 1/21. - One i-Gel Supraglottic Airway size 4 with an expiration date of 4/21. - One i-Gel Supraglottic Airway size 3 with an expiration date of 11/20. - One Cardinal Health Non-Conductive Suction Tubing 10 feet with an expiration date of 1/31/23. Procedure Room Anesthesia Cart: - One BD 5 ml (milliliter) syringe with an expiration date of 5/31/24. - One Cardinal Health Sterile Wooden Tongue Blade with an expiration date of 5/12/22. Labor and Delivery Medication Room: - Two Epidural Sets with an expiration date of 4/1/24. Labor and Delivery Hallway: - Two 2-0 Vicryl J33 with an expiration date of 3/31/24. An interview was conducted on 7/31/24 at 4:55 PM with EI # 5, who confirmed the above supplies were expired and available for patient use. 41623 4. A tour of the Laboratory Department was conducted on 7/31/24 at 2:05 PM with EI # 12, Quality Assurance Director. In the patient blood collection area, 25 blue top blood collection tubes with an expiration date of 5/31/24 were observed and available for patient use. EI # 12 confirmed the collection tubes were out of date and available for patient use at the time of the tour of the department.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 49894 Based on observations, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure staff: 1. Performed hand hygiene per hospital policy. 2. Cleaned the septum (rubber stopper of a medication vial) on all medication vials with alcohol before piercing the septum with a syringe needle per hospital policy. This affected Patient Identifier (PI) # 5 and an unsampled patient in two of four observations of medication administration, one of one observations of a room terminal cleaning, and had the potential to affect all patients served by this hospital. Findings include: Hospital Policy: Hand Hygiene - Centers for Disease Control and Prevention (CDC) Guidelines Reference Number: 4008 Effective Date: 5/11/18 Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs, and infections. Policy: All staff shall use the hand hygiene techniques, as set forth in the following procedure... - Before each patient encounter. - After contact with medical equipment/supplies in patient areas. - Always after removing gloves... Notes: - Always follow Standard Precautions. - Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, non-intact skin, is anticipated. - Change gloves and discard after each patient contact... Hospital Policy: Safe Injection Practices Policy Number: None Revised Date: None Purpose: Unsafe injection practices put patients and healthcare workers at risk for infections... Safe injection practices are part of Standard Precautions... Policy: I. Aseptic technique: refers to the use of various barriers and precautions to prevent the transfer of microorganisms from the healthcare worker and the environment to the patient during a procedure. a. Perform hand hygiene before accessing supplies, handling vials and intravenous (IV) solutions, preparing or administering medications, and conducting point-of-care testing... g. Disinfect the rubber stopper of medication vials...with sterile 70 percent (%) alcohol before inserting a needle... V. Medication Vials and Ampules: ...f. Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial... VIII. Insulin Pens: ...e. Always attach a new sterile needle before each use and for each injection... Before use of the needle, carefully read the “Instructions for Use” accompanying the needles. Instructions for use for most insulin pen needles are as follows:. 1. Wipe the rubber seal with alcohol... f. Clean the area of the skin to be injected with a 70% alcohol prep pad. 1. An observation of medication administration was conducted on 7/31/24 at 8:20 AM. Employee identifier (EI) # 11, Registered Nurse (RN), administered Tresiba 10 units subcutaneously to PI # 5 per physician’s order. Prior to donning gloves, EI # 11 failed to perform hand hygiene per hospital policy. Before attaching a new needle to the insulin pen, EI # 11 failed to wipe the rubber seal with alcohol. An interview was conducted on 8/1/24 at 4:30 PM with EI # 1, Director of Nursing, who confirmed staff failed to follow the hospital policy for hand washing and the hospital policy for safe injection practices. 2. An observation of a patient room terminal cleaning was conducted on 7/31/24 at 8:35 AM with EI # 6, House Keeping. EI # 6 wiped the sink and chair with Oxivir wipes, removed the gloves and applied new gloves. EI # 6 wiped the bedside table with Oxivir, removed the gloves and applied new gloves. EI # 6 then cleaned the bottom drawer of the bedside table with Oxivir, removed the gloves and applied new gloves. EI # 6 then cleaned the toilet bowl with Jax toilet cleaner, removed the gloves and applied new gloves. EI # 6 then wiped the bed mattress, side rails, call light, and bed frame with Oxivir wipes then removed gloves and applied new gloves. EI # 6 failed to perform hand hygiene each time gloves were removed per hospital policy. An interview was conducted on 8/1/24 at 11:10 AM with EI # 5, Infection Preventionist, who confirmed the staff failed to follow hospital policy for hand hygiene. 3. An observation of IV medication administration to an unsampled patient by EI # 3, RN, was conducted on 7/31/24 at 2:15 PM in Emergency Room # 2. EI # 3 removed the cap covering the septum of a sterile 20 cc (cubic centimeter) vial of sterile water, punctured the septum with a 10 cc syringe needle without wiping the septum with alcohol, and withdrew 10 cc of sterile water. EI # 3 then entered the vial a second time to withdraw an additional 1 cc of sterile water without wiping the septum with alcohol. EI # 3 then removed the cap from a sterile vial of Tenecteplase, punctured the septum with the needle of the 10 cc syringe of sterile water without wiping the septum with alcohol and injected the sterile water for reconstitution. An interview was conducted on 8/1/24 at 4:30 PM with EI # 1, who confirmed staff did not follow hospital policy and wipe the septum of the medication vials with alcohol prior to puncturing. 41624 41623”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 46293 Based on observation, hospital policy and procedure, and interview with staff, it was determined the hospital failed to ensure staff placed a chemical indicator strip in a wrapped pair of sterilized forceps, one of four sterilized items available in the Central Sterile Supply Room. This had the potential to affect all patients undergoing surgery at this hospital. Findings Include: Policy Description: Shelf Life- Sterile Storage Policy Number: None Revised Date: None Procedure: ...Packaging shall be secured and contain a chemical change autoclaving tape and chemical indicator strip. An observation was conducted on 7/30/24 at 1:00 PM with Employee Identifier (EI) # 5, Infection Preventionist, in the Central Sterile Supply Room. A wrapped pair of sterilized forceps was randomly chosen to be unwrapped and inspected. There was no chemical indicator strip inside the wrapped forceps to indicate the sterility of the forceps. EI # 5, who was present during the observation confirmed a chemical indicator strip should have been placed inside of the wrapped forceps per hospital policy.”

“REQUIRED OPERATING ROOM EQUIPMENT CFR(s): 482.51(b)(3) The following equipment must be available to the operating room suites: call-in system, cardiac monitor, resuscitator, defibrillator, aspirator, and tracheotomy set. This Standard is not met as evidenced by: 46293 Based on observation and interviews, it was determined the hospital failed to ensure a tracheotomy tray was available for use in the OR (Operating Room). This had the potential to affect all patients that utilized the surgical services at this hospital. Findings Include: An observation was conducted in the Central Sterile Supply Room on 7/30/24 at 1:00 PM with Employee Identifier (EI) # 5, Infection Preventionist. A request was made to see the tracheotomy tray. EI # 5 responded there was no tracheotomy tray in the hospital. An interview was conducted on 8/1/24 at 3:52 PM with EI # 5, who confirmed there was no tracheotomy set on the hospital premises.”

“. K3 Building: 0202 K6 Plan Approval: 10/1991 K7 Survey Under: 2012 Existing K8 BUSINESS: 7,935 sq. ft. Battery Powered Emergency and Exit Lights FACP: None Smoke Detection: None Type of Structure: 1991 single story unprotected combustible, Type V(000) with 2018 additions on the North and South sides of the building. The facility does not have an automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 were MET as evidenced by the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 19.2.1, and 7.2.1.5.1 This deficiency affects 9 of 14 Patient Room Bathrooms. Findings include: During a tour of the facility, the surveyor observed dead bolt locks on the non-egress side of the following Patient Room Bathroom doors; there was no mechanism to unlock these doors on the egress side: 1. 200 2. 201 3. 202 4. 203 5. 204 6. 205 7. 206 8. 208 9. 210 A member of the maintenance staff was present when this deficiency was identified. .”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the exit signage per the requirements of: 2012 NFPA 101, 19.2.10.1, and 7.10.2.1 This deficiency affects the Lobby exit sign. Findings include: During a tour of the facility, the surveyor observed the exit sign over the Main Entrance Lobby Egress Door had two chevron-type indicators directing egress to the left and the right. The correct direction for emergency egress is straight through the door. A member of the maintenance staff was present when the deficiency was identified. .”

“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: 41792 . Based on observation, the facility failed to provide an approved method to ensure appliances that are protected under the hoods, if they are moved, they are returned to the approved design location per the requirements of: 2012 NFPA 101, 19.3.2.5.1, and 9.2.3 2011 NFPA 96, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1 This deficiency affects all equipment under the two kitchen hoods. Findings include: During a tour of the facility, the surveyor observed that the facility failed to provide an approved method to ensure appliances that are protected under the hoods, if they are moved, they are returned to the approved design location. A member of maintenance staff was present when this deficiency was identified. .”

“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: 41792 . Based on review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8 2011 NFPA 25, 14.2.1 This deficiency affects the automatic sprinkler system. Findings include: During the review of the documentation, the facility failed to provide documentation of conducting the automatic sprinkler internal pipe inspection during the past 5 years. A member of the maintenance staff and the administrator were present when this deficiency was identified. .”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to ensure the lay-in ceiling limited the transfer of smoke per the requirements of: 2012 NFPA 101, 19.3.6.2.4 This deficiency affects the Information Technology Room. Findings include: During a tour of the facility, the surveyor observed eleven, 2’ x 2’ ceiling tiles were missing in the Information Technology Room. A member of the maintenance staff was present when this deficiency was identified. .”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 1 of 3 smoke barriers. Findings include: During a tour of the facility, the surveyor observed a 1” unsealed conduit (used as a cable chase) with multiple white cables above the ceiling on both sides of the smoke barrier between 200 Hall and the Nurses Station. A member of the maintenance staff was present when this deficiency was identified.”