D W Mcmillan Memorial Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49797 Based on observations, review of medical records (MR), hospital policy, Bed Census Reports, Physician On-Call List, hospital incident report, Hospital B, receiving hospital MR and interviews, it was determined that D.W. McMillan failed to ensure: 1. The receiving hospital received notification of the transfer. 2. The MR was sent to the receiving hospital. 3. There was an accepting physician’s. 4. The risk of transfer was explained to the patient and/or patient representative. This deficient practice negatively affected Patient Identifier (PI) # 2, and PI # 15, in 2 (two) of seven transfer record reviews, and had the potential to affect all patients presenting to the ED. Findings include: Refer to Tag A 2409.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49797 Based on medical record (MR) review, hospital policy, Hospital Bed Census, Physician Emergency Department (ED) schedule, ED Physician Schedule, On-call list, ED Activity Log, Transfer Log, incident report documentation, Hospital B, (receiving hospital) MR and interviews, it was determined that D.W. McMillan failed to: 1. Obtain an accepting physician for transfer. 2. Explain the risks of transfer. 3. Send copies of the medical record to the receiving hospital. These deficient practices negatively affected Patient Identifier (PI) # 2, and PI # 15, in two of seven transfer records reviewed and had the potential to negatively affect all patients who presented to the hospital. Findings include: Facility Policy: EMTALA Policy Policy number: None listed. Revised: None listed. Purpose: To ensure compliance with the EMTALA and associated regulations. Policy: D.W. McMillan Hospital shall comply with the emergency care obligations imposed by EMTALA. These obligations include the following... 2. Stabilizing treatment If the medical screening examination indicates that the person has an emergency medical condition, D.W. McMillan Hospital will provide treatment with the capabilities of staff and facilities or an appropriate discharge or transfer as indicated. 3. Appropriate Discharge or Transfer A. Stabilized person-If the person is stabilized, the person may be discharged or transferred as appropriate. A person is deemed stabilized under the following circumstances: 1. For discharge : if the person does not need continued care and /or no material deterioration is likely to result is the patient receives continued case as an outpatient or later as an inpatient and the patient is given a plan for appropriate follow-up care. 2. For transfer to another facility: If the person’s emergency medical condition is resolved, although the underlying medical condition may remain, and/or no material deterioration of the person’s condition is likely to result from or occur during transfer... B. Unstabilized person- If the individual is not stabilized, D.W. McMillan will not discharge or transfer the person unless the following conditions are met: 1. Patient’s consent or physician certification 2. Appropriate transfer... 7. Patient’s refusal to Consent. The person has the right to refuse examination, treatment or an appropriate transfer. In such cases, the hospital will offer the individual the examination, treatment or transfer required by EMTALA and document refusal, explain to the individual the risks and benefits of the examination, treatment, or transfer and take reasonable steps to obtain the individual’s written informed refusal... 12. Signs and records. D.W. McMillan Hospital will maintain...Transfer records and a central log on each person presenting to the hospital for emergency care. 1. PI # 2 presented to the ED on 9/21/24 at 8:03 PM with complaints of Vision problems, blurry and red. Review of the ED Activity Log revealed, PI # 2 arrived by auto, checked in at 8:03 PM and checked out at 9:00 PM. The acuity level was semi-urgent with complaints of vision changes and Retinal detachment (an emergency when part of the eye (the retina) pulls away from its normal position) right eye. The discharge disposition was AMA. Review of the Transfer Activity Log dated 9/21/24 revealed PI # 2 was not listed. Review of the Physician Documentation dated 9/21/24 at 8:05 PM revealed, the diabetic patient presented with an experience of a “curtain” falling on his right eye field of vision. Offered to transfer the patient to Pensacola by ambulance but the patient elected transfer by POV and signed out Against Medical Advice (AMA). Review of the ED Triage note dated 9/21/24 at 8:44 PM revealed an acuity level of 4, semi-urgent, vision changes, erythropsia (a visual disturbance in which all objects appear reddish) of right eye. Review of the ED nursing note dated 9/21/24 at 8:55 PM revealed, patient to the ED in personal vehicle complains of vision changes he/she reports as a see-through red curtain over the middle of his visual field of the right eye. Patient denies pain, pupils equal in size and reactive to light. Patient reports diabetes and frequent high blood glucose with no primary care physician oversight currently. Further review of the ED nursing note dated 9/21/24 at 9:00 PM revealed the patient left the ED AMA. The physician recommended transport via Emergency Medical Services (EMS) to Hospital B in Pensacola Fl for higher level of care due to visual changes. Patient refused transport and chose to transport via privately owned vehicle (POV). Review of the Release from Responsibility for Discharge form revealed, risks of leaving, blindness. Benefits of staying, advises pt to go straight to Pensacola via EMS. Patient elected POV transfer. An interview was conducted with PI # 2 on 11/6/24 at 10:42 AM, PI # 2 stated “ I came (to the ED) because my eye was filling up with blood, the doctor thought I had a detached retina.” The patient confirmed he was asked which hospital he wanted to go to and was transferred to “ Hospital B”. He/She also confirmed that paperwork was signed that released him/her to go without the EMS and the risks were explained, but was told to go on and go. When he/she arrived at Sacred Heart, there was not a specialist there. He/she stated an ultrasound was received and was sent to a specialist the next morning. An interview was conducted with EI # 4, Emergency Room (ER) Registered Nurse (RN) on 11/7/24 at 8:05 AM. who confirmed the physician saw PI #2 but there was no ophthalmologist (a physician that is an eye care specialist) available and the physician recommended a higher level of care due to the vision problems. The patient did not want to pay for EMS. An interview was conducted with EI #1, Emergency Room Physician, on 11/7/24 at 8:42 AM. The physician stated PI # 1 was seen in the ER and there was no ophthalmologist available, the patient was told they needed a higher level of care. PI # 2 was told they needed to go to Hospital B by EMS, and the patient refused EMS transport. PI # 2 elected to travel by POV and signed out AMA. EI # 1 did not coordinate care with Hospital B. An interview was conducted on 11/7/24 at 10:32 AM with EI # 2, Medical Director of the Emergency Department. EI #2 stated that if an AMA was used only for the mode of transport then all other elements of the transfer would still apply. A review of the Provision of Care Event form (incident report) dated 9/22/2024 revealed, Patient left against medical advice. The brief factual description documented: Patient presented to ED with visual changes, The physician assessed the patient and suggest transport to Hospital B ER for higher level of care related to them having an ophthalmologist on staff. Patient refused transport by EMS and insisted on transport by private vehicle despite the physician’s warning patient of possibility of further complications including potential blindness. Patient left against medical advice and signed appropriate paperwork. A review of the MR, from Hospital B, revealed, PI # 2 presented to the ED on 9/21/24 at 11:44 PM with an eye problem. A review of Hospital B’s ED Physician note dated 9/21/24 at 11:57 PM revealed, Chief complaint, Patient presents to ER from D.W. McMillian with a diagnosis of detached retina. History of Present Illness, Patient presents with decreased right vision. States at work earlier today he developed a “ dark curtain that flowed down the right eye.” He/she states that he was seen at D.W.McMillan and underwent no imaging, no ultrasound. He/she was told that he was being “transferred” to our facility for definitive management. Denies being signed out Against Medical Advice. Has no paperwork with them. Further review of the physicians note dated 9/21/24 revealed, the physician called the physician at D.W. McMillan to get a better understanding of how the patient ended up in our emergency department with absolutely no record of transfer. He/she states that “ If we call ahead we have to send them by ambulance.” I explained to the physician that we do not have a retinal specialist on tonight and that I would have to transfer the patient elsewhere. A review of the transfer certification revealed no receiving physician was documented. 2. PI # 15 presented to the ED on 9/21/24 at 7:45 PM with complaints of Vomiting, unspecified. Review of the physician’s ED documentation dated 9/21/24 at 7:54 PM revealed PI # 15, a kidney transplant patient, had projectile vomiting since early afternoon. Review of the Transfer Certification dated 9/19/24 at 9:00 PM (correct date is 9/21/24) revealed the risks of transfer for nephrology care, via air medical transport, was not explained and not documented on the transfer document. Further review of the Transfer Certification revealed no copies of the medical record were sent to the receiving hospital. An interview was conducted on 11/6/24 at 2:15 PM with EI # 6, who confirmed there was no documentation the physician explained the risk of transfer to the minor patient’s guardian, and no documentation medical record copies were sent to the receiving hospital. 30952”

“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: 49797 Based on observations and interviews during a hospital tour with hospital staff and the Life Safety Code surveyor, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by this hospital. Findings include: Refer to tags K-0211, K-0223, K-0226, K-0281, K-0353, K-0361, K-0363, K-0372, K-0741, K-0781, and K-0923.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 49797 Based on medical record (MR) review, policy and procedure, and staff interview, it was determined the facility failed to ensure patients were informed of the patient’s rights prior to receiving care at the facility. Findings include: Hospital Policy: Informing Patients of Rights and Responsibilities Initiated: 12/04 Revised: 7/24 Policy Number: Not listed Policy: Patients in all hospital settings are entitled to receive information about their rights and responsibilities while receiving care in that area. A patient representative designated by a patient is also entitled to receive this information. Inpatients: All inpatients will be provided a pamphlet at registration entitled “Information for Patients” which contains patients’ rights. Emergency Room (ER) Patients: All patients who register will be provided a copy of the ER pamphlet “Information for Patients” which contains information on patients’ rights. Outpatient Clinic or Outpatient Surgery Patients: All patients who register to receive services in an outpatient clinic setting or undergoing Outpatient Surgery will be offered a copy of the pamphlet “Information for Outpatients” which contains information on patients’ rights at registration. Outpatient Diagnostic Testing: These patients will be furnished a copy on request. Patient Rights include at least the following: The ability to refuse care. Respect for individual end-of-life decisions. Effective Communication from care-givers. Privacy, security, and confidentiality. Environment that preserves dignity. Freedom from abuse, neglect, or exploitation in any form. Access to protective and advocacy services. Ability to have a family member or friend (including same-sex domestic partner) present for emotional support during patient’s inpatient stay... Medical record review revealed, seven out of 10 emergency room records and two out of 20 inpatient records did not have a signed document confirming the patient had received a copy of their rights prior to receiving care at the facility. An interview was conducted on 9/12/24 at 1:53 PM with Employee Identifier # 2, Director of Nursing, who confirmed the patients did not have a signed document confirming the patient’s rights were given prior to receiving care at the facility. 49894”

“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: 49797 Based on observation and interview, it was determined the hospital failed to ensure: Expired intravenous (IV) fluids and medications were not available for patient use. This deficient practice had the potential to affect all patients receiving care at this hospital. Findings include: 1. During a tour of the Labor and Delivery unit on 9/10/24 at 9:15 AM, with Employee Identifier (EI) # 6, Obstetrics assistant manager, the following IV fluids and medications were observed and available for patient use: a. One 1000 milliliter (mL) bag of Magnesium Sulfate 40 gram (g) with an expiration date of 5/24. b. Two 250 mL bags of normal saline with an expiration date of 6/24. c. Two 10 mL Calcium Gluconate 1000 Milligram (mg) per mL with an expiration date of 5/24. An interview was conducted on 9/10/24 at 10:15 AM with EI # 6, who confirmed the expired IV fluids and medications were available for patient use.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 49603 Based on observations, review of facility policies and procedures, and interviews with staff it was determined the facility failed to ensure: 1. Safe storage of food items in the dietary department. 2. Foods were labeled with the date opened and use by date or expiration date. 3. Expired foods were not available for use. This had the potential to affect all patients admitted to this hospital. Findings include: Facility Policy: Food Storage Policy Number: SOP #303 Issued: 7/18/22 Revised: None Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Procedure: ...Use by date shall be marked on all food containers ... ...Frozen Meat/Poultry and Foods: ...Storage: ...Label and date all food items. 1. A tour of the dietary department was conducted on 9/10/24 at 9:20 AM with Employee Identifier (EI) # 10, Dietary Manager, which included observations in the following areas: a. Dry storage: A full bin of individual Soy Sauce packs, with no use by or expiration date. Rice being stored in a zip lock bag, expired on 8/22/24. Flour, Meal, and Breadcrumbs being stored in separate bins, with no use by or expiration date. Individual packs of Saltine Crackers, Club Crackers, Wheat Crackers and Honeymaide Graham Crackers being stored in separate bins with no use by or expiration date. Three packs of Custom Culinary Chicken Flavored Gravy mix, and Seven packs of Brown Gravy mix being stored in separate bins with no use by or expiration date. b. Cooler: Thirteen eight-ounce Glucerna Therapeutic Nutrition Shakes, Creamy Strawberry expired on 7/1/24. One eight-ounce Glucerna Therapeutic Nutrition Shakes, Rich Chocolate expired on 7/1/24. One eight-ounce Nepro with Carbsteady Therapeutic Nutrition, Butter Pecan expired on 9/1/23. Nine eight-ounce Nepro with Carbsteady Therapeutic Nutrition, Homemade Vanilla expired on 9/1/24. The staff failed to ensure foods were labeled appropriately, stored, and discarded when expired or out of date. An interview was conducted on 9/10/24 at 10:30 AM with EI # 10 who confirmed foods were not stored and labeled per policy.”

“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: 41623 Based on observations 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 this facility. Findings include: 1. A tour of the Surgical Department was conducted on 9/10/24 at 10:15 AM with Employee Identifier (EI) # 19, Operating Room (OR) Manager, and EI # 3, Quality Manager. In the OR Supply Room the following items were observed on the shelf and available for patient use: a. One Silicone Foley Catheter with an expiration date 10/30/23. b. Two PDS II (Brand) Violet Monofilament suture material with an expiration date of 2/28/23. An interview was conducted on 9/10/24 at 10:30 AM with EI # 19 who confirmed the expired supplies were available for patient use. 2. A tour of the Medical/Surgical (MS) Floor was conducted on 9/10/24 at 10:15 AM with EI # 4, MS Case Manager. In the MS Medication and Supply Room the following items were observed in the drawers and cabinets and were available for patient use. a. Two 18 Gauge (G) Needles with an expiration dare of 12/31/22. b. One 18 G Needle with an expiration date of 6/30/22. c. Four 30 G Needle with an expiration date of 10/31/23. d. Two Hollister 14802 Ostomy Barriers with an expiration date of 2/24. e. Five Hollister Wound Drainage Collectors with an expiration date of 1/22. An interview was conducted on 9/10/24 at 10:30 AM with EI # 4, who confirmed the expired supplies were available for patient use. 3. A tour of the Obstetrics unit was conducted on 9/10/24 at 10:15 AM, with EI # 5, Obstetrics Manager. In the hemorrhage cart and supply cart the following supplies were observed and available for patient use. a. Four 16 gauge needles with an expiration date of 6/22. b. Two boxes of sterile gloves with an expiration date of 3/24. An interview was conducted on 9/10/24 at 10:28 AM, with EI # 5, who confirmed the expired supplies were available for patient use. 49797 50417”

“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: 41623 Based on observations, facility policy and procedure, and interviews, it was determined the facility failed to ensure the staff performed hand hygiene per facility policy. This deficient practice affected five of nine observations of care and did affect Patient Identifier (PI) # 3, PI # 5, one unsampled patient and had the potential to affect all patients admitted to this facility. Findings include: Facility Policy: Hand Hygiene Policy Number: not listed Revised Date: 4/24 ...Purpose: To provide guidelines to promote hand hygiene practices and reduce the transmission of pathogenic microorganisms to patients and staff... When to wear gloves: When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infections materials, ... or contaminated equipment)... If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient’s surroundings. Always clean your hands after removing gloves... When to change gloves and clean hands: ... If gloves become soiled with blood or body fluids after a task. If moving from work on a soiled body site to a clean body site... If they look dirty or have blood or body fluids on them after completing a task. Before exiting a patient room... 1. An observation of medication administration was conducted on 9/10/24 at 9:34 AM. EI # 11, Registered Nurse (RN), administered intravenous (IV) push Morphine to PI # 3. No hand hygiene or gloves were utilized before or during procedure. An interview was conducted on 9/10/24 at 9:45 AM with EI # 4, who confirmed staff failed to perform hand hygiene per facility policy. 2. An observation of medication administration was conducted in the Emergency Department on 9/10/24 at 10:20 AM. EI # 9, RN, administered IV antibiotics to an unsampled patient. EI # 9 handled the computer equipment, scanned the IV medication to be given, touched the patient’s bed, and scanned the patient’s identification bracelet. Then, without changing gloves and performing hand hygiene, EI # 9 hung the medication and connected the IV line to the patient’s IV. An interview was conducted on 9/12/24 at 1:30 PM with EI # 1, who confirmed staff failed to change gloves and perform hand hygiene between tasks per facility policy. 3. An observation of medication administration was conducted in the Intensive Care Unit, Room 203, on 9/10/24 at 3:40 PM. EI # 8 administered IV antibiotics to PI # 5. EI # 8 handled the computer equipment, scanned the IV medication to be given, touched the patient’s bed, bed covers, and scanned the patient’s identification bracelet. Then, without changing gloves and performing hand hygiene, EI # 8 hung the IV medication and connected the line to the patient’s IV. An interview was conducted on 9/12/24 at 1:30 PM with EI # 1, who confirmed staff failed to change gloves and perform hand hygiene between tasks per facility policy. 4. An observation of terminal cleaning of an Operating Room (OR) was conducted on 9/10/24 at 2:30 PM. EI # 17, Environmental Services, wiped the anesthesia cart, trash receptacle, and work station with a cloth with disinfecting solution. EI # 17 exited the OR room, then reached into his/her pockets with soiled gloves on to retrieve the keys to the cleaning cart. EI # 17 then removed a new cleaning cloth from the cart, re-entered the OR room and continued cleaning surfaces. EI # 17 failed to remove gloves and perform hand hygiene when exiting the OR, before and after reaching into pockets, and before retrieving items from the clean cart. An interview was conducted on 9/12/24 with EI # 3, Quality Manager, who confirmed the staff failed to perform hand hygiene per facility policy. 5. During a tour of the Labor and Delivery unit on 9/10/24 at 10:34 AM with EI # 5, Obstetrics manager, and EI # 6, Obstetrics assistant manager, an open box of Cervidil with a substance that appeared to be blood on the box was noted in the refrigerator with two unopened boxes of Cervidil and was available for patient use. An interview was conducted on 9/10/24 at 10:34 AM with EI # 5 who confirmed the substance was blood and the Cervidil was available for patient use. 49797 49894 50417”

“. K3 Building: 0101 K6 Plan Approval: 1956/1963/1965/1967/1971/1973/1975/1979/1990/1996/2000/2015 K7 Survey Under: 2012 Existing K8 HOSP Generators: Generator #6 Natural Gas, Baldor 50kW (installed 2010) Generator #7 Diesel, Baldor 225kW (installed 2012) Generator #8 Diesel, Taylor 400kW (installed 2014) FACP: Simplex 4100ES (installed 2015) Locking Devices: None Smoke Detection: Corridor Beds: 91 Census: 10 Type of Structure: 1956/1963/1965/1967/1971/1973/1975/1979/1990/1996/2000/2015 two story unprotected noncombustible, Type II(000). This building has a complete automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 were not met as evidenced by the following deficiencies of 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 7.2.1.9.1.3 This deficiency affects 1 of 2 Operating Room (O.R.) area means of egress. Findings include: During a tour of the facility, the surveyor observed the O.R. egress door (across the hall from the O.R. Waiting Room) did not have a sign on the egress side that reads, “IN EMERGENCY, PUSH TO OPEN”. A member of the maintenance staff was present when this deficiency was identified. .”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the magnetic hold open devices for a set of cross-corridor fire doors per the requirements of: 2012 NFPA 101, 19.2.2.2.7, and 7.2.1.8.2(4) This deficiency affects 1 set of cross-corridor fire doors. Findings include: During a tour of the facility, the surveyor observed the magnetic hold open devices for the pair of cross-corridor fire doors between the Intensive Care Unit Hall and Hall 1, failed to release during loss of power to the fire alarm system. A member of the maintenance staff was present when this deficiency was identified. .”

“Horizontal Exits CFR(s): NFPA 101 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a horizontal exit per the requirements of: 2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1 This deficiency affects 1 horizontal exit. Findings include: During a tour of the facility, the surveyor observed an unsealed opening of a 3” conduit, used as a chase, for multiple cables in the 2-hour fire barrier above the ceiling over the cross corridor doors between Obstetrics and Radiology. A member of the maintenance staff was present when this deficiency was identified. .”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to provide continuous illumination of the means of egress per the requirements of: 2012 NFPA 101, 19.2.8, and 7.8.1.4 This deficiency affects both Education Center exits. Findings include: During a tour of the facility, the surveyor observed a single wall mounted fixture with a single bulb (no continuous illumination of the means of egress) at the two Education Center exits. A member of the 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: 42853 . Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.5 2011 NFPA 25, 5.3.1.1.1.3 This deficiency affects entire facility Findings include: During a tour of the facility, the facility failed to provide documentation that the 1999 fast-response sprinkler heads found throughout the facility had been replaced or a representative sample tested within 20 years of installation. A member of the maintenance staff was present when this deficiency was identified. .”

“Corridors - Areas Open to Corridor CFR(s): NFPA 101 Corridors - Areas Open to Corridor Spaces (other than patient sleeping rooms, treatment rooms and hazardous areas), waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are in accordance with the criteria under 18.3.6.1 and 19.3.6.1. 18.3.6.1, 19.3.6.1 This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to maintain areas open to the corridor per the requirements of: 2012 NFPA 101, 19.3.6.1 (1) (c) This deficiency affects 1 alcove. Findings include: During a tour of the facility, the surveyor observed file cabinets in an alcove open to the corridor (without an electrically supervised automatic smoke detection system) on Hall 1 next to the Case Management Office. This space did not allow direct supervision by the facility staff from a Nurses’ Station or similar space. A member of the maintenance staff was present when this deficiency was identified. .”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a corridor door per the requirements of: 2012 NFPA 101, 19.3.6.3.5 42 CFR 482.41 (b) (1) (ii) S&C-07-18 This deficiency affects 1 corridor door. Findings include: During a tour of the facility, the surveyor observed the Business Office Break Room’s corridor door had a 3/4” gap between the door and door frame when the door was closed and latched, prohibiting the door from being smoke resistive. 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 smoke barriers 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 smoke barrier. Findings include: During a tour of the facility, the surveyor observed an unsealed penetration of a 1/2” copper oxygen pipe above the ceiling, over the cross-corridor doors of the smoke barrier between the Emergency Department and Radiology. A member of the maintenance staff was present when this deficiency was identified. .”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to maintain the permitted smoking area per the requirements of: 2012 NFPA 101, 19.7.4, (6) This deficiency affects 2 of 2 designated smoking areas. Findings include: During a tour of the facility, the surveyor observed the two permitted smoking areas failed to have metal containers with self-closing cover devices. A member of the maintenance staff was present when this deficiency was identified. .”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to prohibit a portable space heating device per the requirements of: 2012 NFPA 101, 19.7.8 This deficiency affects 1 of 2 on-call sleeping rooms. Findings include: During a tour of the facility, the surveyor observed a portable space heating device on the carpeted floor in the Doctors On-call Room in the Operating Room Area. This was located in a sleeping smoke compartment and the facility was unable to provide documentation that the heating element did not exceeding 212 degrees. A member of the maintenance staff was present when this deficiency was identified. .”

“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: 42853 . Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of: 2012 NFPA 99, 11.3.2.3 This deficiency affects 1 of 1 outside oxygen cylinder storage. Findings include: During a tour of the facility, the surveyor observed the outside oxygen storage roof frame was made out of wood and was within 5 feet of the oxygen cylinders. A member of the maintenance staff was present when this deficiency was identified.”