Medical Center Barbour

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 40119 Based on review of medical records (MR), hospital policies and procedure, home health agency MR, and interviews, it was determined the facility failed to ensure staff: 1. Documented complete wound care orders. 2. Performed wound care as ordered. 3. Performed wound assessments per the hospital policy. 4. Documented the position of the patient every two hours accurately and/or as ordered by the physician. These deficient practices did affect two of three MRs reviewed with wounds, including Patient Identifier (PI) # 1 and PI # 3, and had the potential to affect all patients served by the hospital with wounds. Findings include: Hospital Policy: Pressure Ulcer Treatment/Alteration of Skin Integrity Treatment Policy Number: Not documented Scope: Nursing Services Reviewed Date: 1/24 ...Policy: Patients will be assessed on admission, by an RN (Registered Nurse), and daily, by a licensed nurse ... the nurse will implement appropriate wound management strategies ...and document in the patient’s MR at a minimum and as applicable: The stage of the wound ... Location ... Describe tissue type and/or wound bed (granulation, necrotic, eschar, slough, and/or epithelial), Size including length, width, and depth in centimeters (cm) (every 7 days), Presence and location of tunneling and/or undermining, describe exudate/drainage (odor, color, type, and/or character), describe surrounding tissue ... Procedure: An RN will perform assessment of the patient on admission to inspect for breaks in the integrity of the skin. A licensed nurse will reassess daily... All assessments, interventions, and consults will be documented in the patient’s MR ... Hospital Policy: Patient Assessment Policy Number: Not documented Scope: Nursing Services Reviewed Date: 12/23 ...Policy: ...Significant changes in assessment are reported to the attending physician (i.e... wounds...). 1. PI # 1 was admitted to the hospital on 3/3/24 with diagnoses including Acute Urinary Tract Infection, Altered Mental Status, and Acute Kidney Injury. Review of the nursing note dated 3/4/24 at 8:00 AM revealed the patient had a stage 2 pressure ulcer on the buttocks. There was no documentation of the exact location of the ulcer, the wound bed, the size, the presence of tunneling and/or undermining, exudate/drainage, and the surrounding tissue. There was no documentation the physician was notified of the stage 2 pressure ulcer to the buttocks. Review of the 15 nursing shift assessments dated 3/5/24 until discharge on 3/12/24 revealed no documentation of the stage 2 pressure ulcer documented on 3/4/24. Review of the PT (Physical Therapy) Initial Evaluation dated 3/11/24 revealed the patient was maximum assistance for bed mobility, including turning and changing position. Review of the Patient Activity (every two hour turning and repositioning) entries dated 3/11/24 to 3/12/24 revealed 21 of 31 entries failed to document the position of the patient, and 10 of the 31 entries revealed documentation the patient could turn her/himself. Review of the MR revealed PI # 1 was discharge home with home health on 3/12/24. Review of the home health agency admission note dated 3/13/24 revealed the patient was maximal assistance for bed mobility, had a stage 2 pressure ulcer to the sacrum measuring 3 cm (centimeters) in length, 0.5 cm in width, and 0.1 cm in depth, maceration (A softening and breaking down of skin resulting from prolonged exposure to moisture) to the groin with peeling skin, and a rash to the groin and between the thighs. An interview was conducted on 7/10/24 at 9:36 AM with Employee Identifier (EI) # 9, Physical Therapist (PT) who performed the PT evaluation. EI # 9 verbalized when maximum assistance with bed mobility is documented, it means the patient is unable to do anything on their own, even if asked to roll to side, the patient is unable to do so. EI # 9 also verbalized PI # 1 had difficulty following commands and could not turn at all. EI # 9 further verbalized PI # 1’s eyes would be open, but he/she couldn’t give a verbal reply and most of the time when shown a command, such as raising an arm, the patient did not follow the command. An interview was conducted on 7/10/24 at 10:34 AM with EI # 6, Licensed Practical Nurse (LPN), who performed PI # 1’s discharge on 3/12/24. EI # 6 verbalized when a patient had been in the hospital several days and no report (from other nurses/staff) was received the patient had a wound, “I don’t necessarily check” the patient’s skin for a wound when performing a skin assessment. EI # 6 verbalized, “...I don’t go looking for something that wasn’t reported to me. Also, if the patient is not complaining of discomfort, I don’t look...” An interview was conducted on 7/10/24 at 2:05 PM with EI # 1, Quality and Risk Director, and EI # 2, Chief Nursing Officer, who confirmed the hospital staff failed to perform wound assessments per the hospital policy and documented the patient’s position accurately. EI # 1 and EI # 2 confirmed there was no documentation the physician was notified and/or aware of the stage 2 pressure ulcer to the buttocks. 2. PI # 3 was admitted to the hospital on 7/3/24 with diagnoses including Pressure Injury of Sacral Region of back Stage IV (four) and Paraplegia. Review of the Provider orders dated 7/3/24 at 4:17 PM revealed an order to turn the patient from side to side every two hours. Review of the Patient Activity entries dated 7/3/24 to 7/8/24 revealed 107 of 113 entries failed to document the position of the patient in the bed and 20 of the 113 entries revealed documentation the patient could turn him/herself. Review of the Provider orders dated 7/4/24 at 2:24 PM revealed an order to perform a wet to dry dressing change with Dakin’s solution (mixture of sodium hypochlorite and boric acid diluted in water), gauze, and tape twice daily. There was no documentation of the wound location for the dressing change. Review of the Provider orders dated 7/4/24 at 4:49 PM revealed an order to perform a wet to dry dressing change with Dakin’s solution, gauze, and tape every 12 hours. There was no documentation of the wound location for the dressing change. Review of the nursing notes dated 7/5/24 revealed no documentation wound care was performed per the provider order. Review of the five nursing notes dated 7/6/24 to 7/8/24 revealed the patient had a sacral wound with tunneling of 2 to 3 cm. There was no documentation of the location of the tunneling to the wound. Review of the nursing notes dated 7/7/24 revealed wound care was provided at 4:00 AM and 9:00 AM, which was 5 hours apart instead of the 12 hours per the provider order. There was no documentation wound care was provided again on 7/7/24. Review of the Provider orders dated 7/8/24 at 12:58 PM revealed an order to clean and pack wound with Dakin’s solution, cover with gauze, and reinforce with paper tape and abdominal pad twice a day and as needed when soiled. There was no documentation of the wound location for the dressing change. An observation was conducted on 7/8/24 at 5:00 PM with EI # 3, LPN, and EI # 4, Registered Nurse, to observe wound care provided to PI # 3. Prior to performing the wound care, EI # 3 and EI # 4 turned the patient to the right side using the bed sheet and EI # 4 continued to hold the patient on the right side along with adjusting the position of the patient due to the patient’s inability to perform any action to facilitate turning or repositioning self. During the wound care, the following four wounds were observed along with red blanchable areas surrounding each wound. a. Wound one was to the sacral area, with a necrotic wound bed. The wound measured 9.5 cm in length, 7 cm in width, and 1.75 cm in depth with tunneling at approximately the 7 o’clock position of 2.25 cm and at the approximately 11 o’clock position of 1.5 cm. The wound was provided per orders. b. Wound two was a stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) to the left buttock measuring approximately (surveyor observation) 6 cm in length, 2 cm in width, and 0.1 cm in depth. The wound was covered with an abdominal dressing and tape. The staff failed to clean and pack the wound with Dakin’s solution and cover the wound with gauze. c. Wound three was a deep tissue injury (DTI, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues.) with a black center to the left gluteal fold. The wound measured (performed by EI # 3) 1.75 cm in length, 2 cm in width, and 0 cm in depth, a moisture barrier cream was applied to the wound. There was no documentation of a provider order for a moisture barrier. d. Wound four was a DTI to the right gluteal fold with a dark red/maroon center. The wound measured (performed by EI # 3) 0.25 cm in length, 0.5 cm in width, and 0 cm in depth, a moisture barrier cream was applied to the wound. There was no documentation of a provider order for a moisture barrier. Review of the nursing note dated 7/8/24 at 5:00 PM revealed the nurse failed to document the sacral wound tunneling at the approximately 11 o’clock position. There was no documentation of wound two, wound three, and wound four. Further review of the nursing note dated 7/8/24 at 5:00 PM revealed the nurse documented education was provided to the patient on turning every two hours. There was no education on turning every two hours provided to the patient during the observation. Interviews were conducted on 7/10/24 with three staff members, two nurses and one patient care technician, who had cared for PI # 3 during the hospital stay. The three staff members verbalized PI # 3 had not been able to turn and reposition self in the bed from the time of admission through 7/10/24. An interview was conducted on 7/10/24 at 1:49 PM with EI # 1 and EI # 2 who confirmed the hospital staff failed to document complete wound care orders, perform wound care as ordered, and failed to perform wound assessments per the hospital policy.”

“. K3 Building: 0304 K6 Plan Approval: 1995 K7 Survey Under: 2012 Existing K8 Hosp Generator: One Diesel, Caterpillar 750 kW (installed 1998) Fire Alarm: Notifier DRD4, cellular communication (installed 2007) Locking Devices: Full time magnetic at both the ED an OR entrances from the hospital, the ED’s ambulance entrance is access-controlled egress doors, and the ED’s entrance from the ED Waiting Area is electronic and key operated. Smoke Detection: Complete Corridor Beds: 35 Census: 23 Type of Structure: 1995 ED and OR addition two story protected noncombustible, Type II (111). This building has a complete automatic sprinkler system. During an initial survey for this hospital to become a Critical Access Hospital conducted on this date, this building was found not in compliance with the requirements of 42 CFR, 482.41 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 Surveyors while accompanied by the facility maintenance personnel. .”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 49600 . Based on observation, the facility failed to maintain an emergency release switch for the full-time magnetic locks on the Geri-psych Hall per the requirements of: 2012 NFPA 101, 19.2.2.2.5.2 (1), and 19.2.2.2.6 This deficiency affects 1 of 3 full-time magnetic locks. Findings include: During a tour of the facility, the surveyor observed one of the full time magnetic locked egress doors (East side/Macon Street exit) on the Geri-psych Hall failed to automatically unlock upon activation of the emergency release switch. 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 two sets of cross-corridor fire doors per the requirements of: 2012 NFPA 101, 19.2.2.2.7, and 7.2.1.8.2 This deficiency affects two sets of cross-corridor fire doors. Findings include: During a tour of the facility, the surveyor observed (on the Back Hall between the Main Hospital Building and Geri-psych), the following magnetic hold open devices failed to release during loss of power to the fire alarm control panel: 1. The cross-corridor doors in the 2 hour-rated fire wall that separates the three story construction type from the single story construction type (between Maintenance Shop/Boiler Room) 2. The cross-corridor doors in the 2 hour-rated fire wall between Tele-Computer Room/Storage 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: 49600 . Based on observation, the facility failed to maintain a set of access control doors per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, 21.9 This deficiency affects 1 set of 2 sets of access control doors. Findings include: During a tour of the facility, the surveyor observed the access control doors (between the Main Hospital Building and the Operating Room Suite) on the second floor failed to automatically release upon loss of power to the fire alarm system. 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 Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 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 smoke doors per the requirements of: 2012 NFPA 101, 19.3.7.8, 8.5.4.4, and 7.2.1.8.2 This deficiency affects one set of cross-corridor smoke doors of one set on the third floor. Findings include: During a tour of the facility, the surveyor observed the magnetic hold open devices for the set of cross-corridor smoke doors on the 3rd floor between Patient Rooms 307/309 failed to release during loss of power to the fire alarm control panel. A member of the maintenance staff was present when this deficiency was identified. .”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to provide a remote manual stop station for the emergency generator per the requirements of: 2012 NFPA 101, 19.2.9.1, and 7.9.2.4 2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1 This deficiency affects one of one generator. Findings include: During a tour of the facility, the facility failed to provide a labeled, remote manual stop station for the 750 kW emergency generator. This was required when this generator was installed, in 1998. A member of the maintenance staff was present when this deficiency was identified.”