Red Bay Hospital

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 41624 46293 Based on observations, hospital policy, and staff interviews, it was determined the hospital failed to ensure expired supplies were not available for patient use. This had the potential to negatively affect all patients served by this hospital. Findings include: Hospital Policy: Guidelines for Disposable Items - Handling, Storage, Use and Reuse, IC (infection control) - 213 Policy Number: 13107815 Effective Date: 02/2023 Policy: ...2. Disposable items will be stored...according to manufacturer’s specifications... 4. No items shall be used after expiration dates... 1. A tour of the Emergency Department (ED) was conducted on 8/20/24 at 11:20 AM. The following supplies were observed as expired and available for patient use within the ED: Trauma/Bay 4: - Eight Covidien Polysorb Braided Absorbable Sutures, size 4-0, from a 32 count box with expiration date 7/31/24. - Three Shiley 4.0 mm (millimeter) Oral-Nasal Tracheostomy Cuffed Tubes with expiration date 8/14/24. One tube was in the pediatric airway box, the other two were in the purple drawer of the respiratory cart. - 12 size 8.5 Protexis Latex Micro Surgical Gloves with expiration date 7/31/24. - Two Becton Dickinson (BD) Insyte Autoguard 16 g (gauge) IV (intravenous) catheters with expiration date 4/30/24. ED Bay 2: - One BD Smart Site Extension Set with 0.2 Micron Low Protein Binding Filter with expiration date 5/27/24. - One B Braun Filtered Extension Set with expiration date 10/31/23. Employee Identifier (EI) # 4, Registered Nurse, confirmed the expired supplies at the time of the tour. 2. A tour of the Central Supply Room was conducted on 8/20/24 at 12:50 PM. The following items were found to be expired and available for patient use: - One Cardinal Health Non-Conductive Suction Tubing with an expiration date of 7/1/24. - Six Covidien Kangaroo EPump ENPlus Spike with Flush bag with an expiration date of 6/30/24. - Five Large Black Foam Kits with Triple Release Transeal with an expiration date of 8/2/24. - 136 BD Smart Site Extension Sets with an expiration date of 5/27/24. EI # 5, Materials Management, confirmed the expired supplies at the time of the tour. 3. A tour was conducted on 8/20/24 at 2:02 PM of the Emergency Room Supply Room. The following supplies were found to be expired and available for patient use. - 45 Cardinal Health Protexis Latex Micro-Surgical Gloves with an expiration date of 7/31/24. - Three BD Safety Glide Insulin Syringes 1 ml (milliliter) with an expiration date 4/30/24. - One Care Fusion Bone Marrow Aspiration/Intra Osseous Infusion Needle with an expiration date of 5/8/24. - 14 BD Spinal Needles 22 g x (by) 1 inch with an expiration date of 4/30/24. - 124 rolls of 3M brand Micropore Surgical Tape with an expiration date of 4/18/24. EI # 5 confirmed the expired supplies at the time of the tour. 4. An observation of the Medical Surgical Crash Cart on 8/20/24 at 2:53 PM revealed the following expired items: - Four BD Secondary Sets - Three with an expiration date of 1/20/23 and one with an expiration date of 4/30/24. - One ICU brand Medical Primary Plum Set with an expiration date of 7/1/24. EI # 5 confirmed the expired supplies at the time of the observation.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 46293 Base on review of Emergency Preparedness (EP) documentation, and interview with staff, it was determined the hospital failed to ensure their comprehensive EP Program was updated and reviewed biennially (every two years) to comply with the Federal EP requirements. This had the potential to negatively affect all staff and patients at this hospital. Findings include: A review of the Emergency Management Plan (EP Plan and Program) revealed the last revision date was 3/08 and the last review date was 1/17. An interview was conducted on 8/22/24 at 3:32 PM with Employee Identifier # 3, Director of Plant Operations, who confirmed there was no documentation the Emergency Management Plan had been updated and reviewed every two years as required.”

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 46293 Based on review of the hospital’s Emergency Management Plan (Emergency Preparedness) policies and procedures, and interviews with staff, it was determined the hospital failed to ensure policies and procedures were updated and/or reviewed every two years. This had the potential to negatively affect all staff and patients at this hospital. Findings include: A review of the Emergency Management Plan provided to the surveyor revealed the policies and procedures for Emergency Preparedness (EP) were last reviewed on 1/17. An interview was conducted on 8/22/24 at 3:32 PM with Employee Identifier # 3, Director of Plant Operations, who confirmed there was no documentation the EP policies and procedures had been reviewed and updated every two years.”

“. K3 Building 0101 K6 Plan Approval: 1966, 1981, 1994, 1995 K7 Surveyed Under: 2012 Existing K8 Hospital Generator: One Diesel, Perkins 280 kW (installed 2021) FACP: Fire Control Instruments, model FC72 (installed 1995) Piped Gas: Only Oxygen Smoke Detection: Corridor Locking Devices: None No surgeries or procedures, the facility does not keep patients on life support Bed: 25 Census: 8 Type of Structure: 1966, 1981, 1994, 1995 one story unprotected noncombustible, Type II(000). The facility 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. .”

“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 the smoke and fire doors per the requirements of: 2012 NFPA 101, 19.2.2.2.7, and 7.2.1.8.2(4) This deficiency affects all cross-corridor smoke and fire doors. Findings include: During a tour of the facility, the surveyor observed the magnetic hold open devices for all pairs of the cross-corridor smoke and fire doors, 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 two of the three 2-hour fire barriers. Findings include: During a tour of the facility, the surveyor observed unsealed penetrations above the ceiling in the following 2-hour fire barriers: 1. A 3/4” EMT conduit used as a chase for one black cable over the door between C.T. Hall and Therapy 2. Multiple gray and blue cables over the door between X-Ray Hall and Data Room 2 A member of the maintenance staff was present when this deficiency was identified. .”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, Table 14.3.1(9)(h) This deficiency affects all smoke detectors. Findings include: During a tour of the facility, the facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months. A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to install quick-response sprinklers per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1) 2010 NFPA 13, 8.3.3.2, and 8.3.3.4 This deficiency affects 1 of 6 smoke compartment. Findings include: During a tour of the facility, the surveyor observed a quick-response sprinkler head installed in the same compartment (the 1981 addition corridor, patient rooms 118-122) with standard-response sprinkler heads. 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: 41792 . Based on observation and review of documentation, the facility failed to maintain the automatic sprinklers per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.5 2011 NFPA 25, 5.3.1.1.1.6 This deficiency affects 2 of 2 dry sprinklers. Findings include: During a tour of the facility, the facility failed to provide documentation that the 2013 side-wall dry sprinklers, located on the outside over the old smoking area (east end of hospital outside of the 1981 addition) had been replaced or a representative sample tested within 10 years of installation. A member of the maintenance staff and the administrator were 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, 19.3.6.3.4 This deficiency affects 1 corridor door. Findings include: During a tour of the facility, the surveyor observed the Case Managers Office corridor door had an undercut of 1 1/4” gap between the floor and bottom of the door; prohibiting the door from being smoke resistive. A member of the maintenance staff was present when this deficiency was identified.”