Mcgehee Hospital

“BUILDING SAFETY CFR(s): Except as otherwise provided in this section, the CAH must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6). (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities Code do not apply to a CAH. (2) If application of the Health Care Facilities Code required under paragraph (e) of this section would result in unreasonable hardship for the CAH, CMS may waive specific provisions of the Health Care Facilities Code, but only if the waiver does not adversely affect the health and safety of patients. This Standard is not met as evidenced by: 48468 Based on document review and staff interview, the facility failed to provide documentation for the following required inspection, testing, and maintenance activities, and has the likelihood of affecting the health and safety of patients, staff, and visitors by preventing the facility from ensuring critical life safety systems, emergency power systems, water systems, fire protection systems, and environmental controls are functioning properly and maintained in accordance with regulatory standards. “ Battery backup light inspections “ Electrical panel and infrared inspections “ Ceiling tile inspections “ Smoke and fire damper inspections “ Emergency door inspections “ Generator weekly run tests with supporting documentation “ Generator fuel documentation “ Generator battery checks “ Monthly generator load testing “ Load bank testing “ Emergency generator light testing “ Polarity and tension testing on emergency receptacles “ Facility inspections “ Water temperature checks “ Ice machine checks “ Backflow preventer (RPZ) inspections “ Boiler stack inspections “ Sprinkler riser inspections “ Air filter logs Findings include: 1. The facility was unable to provide inspection logs or maintenance records demonstrating battery backup light inspections were completed monthly as required by NFPA 101 and 99. 2. The facility failed to provide yearly electrical panel and infrared inspection documentation required under NFPA 101 and 99. 3. Documentation for monthly ceiling tile inspections was not available for review. 4. The facility could not provide required five-year smoke and fire damper inspection documentation or maintenance logs as required under NFPA 90A and ADH Physical Plant standards. 5. Required yearly emergency door inspection records and inspection checklists were unavailable. 6. Generator weekly run test documentation, including run logs, battery testing, and load test reports, was incomplete or unavailable for review. 7. No evidence of Weekly generator fuel records was presented to show was not maintained. 8.No evidence of Generator battery check was presented in documentation and required battery testing reports were unavailable. 9. No evidnece of Monthly generator load test was presented and documentation not available for review. 10. No eveidence of Annual load bank testing was presented and documentation was not provided during survey. 11. No evidence of Monthly emergency generator light testingwas presented and logs were unavailable. 12. No evidence of Required yearly polarity and tension test reports for emergency receptacles was presented and were not available. 13. No evidence of Weekly facility inspection documentation was presented an incomplete or unavailable. 14. No evidence of Weekly water temperature logs and water treatment plan documentation was presented and were unavailable for review. 15. No evidence of Monthly ice machine cleaning, maintenance, and temperature logs was presented and were not maintained. 16. No evidence of Annual backflow preventer inspection and maintenance records was presented and were unavailable. 17. No evidence of Daily boiler stack inspection and testing logs was presented and were not available 18. No evidence of Annual sprinkler riser inspection and testing documentation was presented and were not provided. 19. No evidence of Monthly air filter maintenance logs was presented and were unavailable.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 50014 C-1006 Based on review of policy and procedures, observations, and interviews it was determined that the facility failed to have a policy in place regarding the monitoring of telemetry units. The failed practice placed the patients at risk of going into a fatal heart rhythm while not being monitored and had the likelihood to affect all patients on telemetry in the facility. Findings follow: A. Review of McGehee Hospital Policy “Emergency Department Cardiac Monitoring” effective 09/20/2022, showed “To be ensure timely identification, monitoring, and management of patients with actual or potential cardiac instability through continuous cardiac monitoring in the emergency department. Applies to all ER clinical staff involved in patient care, including physicians, nurses and clerks.” B. Review of McGehee Hospital Policy “Nursing Cardiac/Telemetry Monitoring: effective 02/05/2015, showed “To provide guidelines for implementation of cardiac/telemetry monitoring for any patient requiring continuous cardiac monitoring, but not requiring intermediate or intensive care. The Telemetry/Cardiac Monitoring station should be attended at all times by a staff member who has attended Cardiac Arrythmia class and passed a competency exam OR is certified in ACLS.” C. Observation on 05/04/26 at 1:35 PM, showed RN #2 was walking between Emergency Room and technician was not in front of Telemetry monitor. D. Observation on 05/04/26 at 1:35 PM, showed Telemetry monitor was not being watched. RN #2 stated that “Today is a busy day.” Noted that the patient in observation telemetry was off. Staff aware at that time. E. Observation on 05/05/26 at 1:15 PM, showed no one at the telemetry monitor. F. In an interview with Director of Emergency Services on 05/04/26 at 2:45 PM, she stated “Medical Surgery and ER share telemetry. Usually, there would be someone sitting in front of the monitor. We also rely on the nurses in the Medical Surgical floor to observe any issues and we reciprocate for them.” G. In an interview with RN #1 on 05/05/26 at 1:25 PM, she stated “We all watch the telemetry board. The ER monitors our telemetry so that we have a backup. There are times when no one is at the desk watching because of the census.” H. In an interview with the CNO (Chief Nursing Officer) 05/04/26 at 1:32 PM, she stated “We try to keep on eye on the telemetry monitors. We do not have a dedicated technician hired any longer.””

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 31039 Based on review of facility policy, medication error reports and interview, it was determined the lack of scanning patient identification barcodes at bedside prior to administering medications per policy) caused medication errors for 5 of 5 (#1, and #3-6) incidents reviewed that involved nursing not scanning the patient identification barcodes prior to dispensing. By not scanning patient identification barcodes prior to administering medications, the facility could not assure patients were receiving the correct medications. The failed practice had the likelihood to affect all patients receiving medications at the facility. Findings follow: A. Review of facility policy titled, “Administration of Medications,” revised 11/18/2015, showed nurses on the Medical Surgical floor were to utilize the CPSI Med-Verify application to identify the correct patient, dose, drug, time and route. The application is to be utilized for the safe and effective administration of medication to the patients on the Medical Surgical floor. B. Review of medication error reports showed the following: 1) Incident #1 showed a dose of Amlodipine 10 milligram (mg) was administered to the wrong patient. The conclusion notes of the investigation showed bedside scanning of the patient’s identification barcode and the medication would prevent future occurrences of this type. 2) Incident #3 showed a dose of Omeprazole 20 mg was given at 1833. The patient and family stated it was not given. The recommendations/actions notes of the investigation showed medication scanning was to be completed at bedside. 3) Incident #4 showed a nurse discovered the wrong type of Intravenous Fluid (IV) was hung. The conclusion notes of the investigation showed bedside scanning of the patient’s identification barcode at the bedside would have prevented this error. 4) Incident #5 showed a patient received an incorrect IV fluid. The conclusion notes of the investigation showed the nurse did not perform the 7 rights of medication administration by not verifying the correct medication. The recommendation/actions notes of the investigation showed scanning before administration would have prevented this error. 5) Incident #6 showed a dose of Symbicort was charted as administered at 1013. Patient stated she did not get it. Recommendation/actions notes showed bedside scanning should be used to reduce medication errors. C. During an interview on 05/05/2026 at 10:00 AM, the director of Pharmacy verified the nurses are supposed to be scanning the patient identification barcodes at bedside prior to administering medications. D. During an interview on 05/05/2026 at 10:15 AM, the Director of Nursing verified the nurses are supposed to be scanning the patient identification barcodes at bedside prior to administering medications.”

“REHABILITATION THERAPY SERVICES CFR(s): Physical therapy, occupational therapy, and speech-language therapy pathology services furnished at the CAH, if provided, are provided by staff qualified under State law, and consistent with the requirements for therapy services in §409.17 of this subpart. This Standard is not met as evidenced by: 31039 Based on review of the Occupational Therapist’s (OT) Job Description, review of Occupational Therapist’s personnel file and interview, it was determined one (OT #1) of two (OT #1-#2) did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification, per Occupational Therapist’s (OT) Job Description. By not having evidence of this qualification, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that receive Rehabilitation Services. Findings follow: A. Record review of Occupational Therapist’s (OT) Job Description showed they were to maintain current CPR certification. B. CPR certification was requested upon entrance and was not received for OT #1. C. During an interview on 05/05/2026 at 2:19 PM, the Rehabilitation Director verified OT #1 did not have a current CPR certification.”

“RECORDS SYSTEM CFR(s): (1) The CAH maintains a clinical records system in accordance with written policies and procedures. This Standard is not met as evidenced by: 31039 Based on review of facility policy and interview, it was determined the facility failed to maintain a clinical records system in that the Information Systems Director had not collected or was not provided records of information system activity, according to policy, for the previous twelve out of twelve (May 2025-April 2026) months. By not implementing procedures to regularly review records of information system activity, the facility could not assure the security and privacy of their patients’ medical records. The failed practice had the likelihood to affect all patients treated at the facility. Findings follow: A. Record review of the facility’s policy titled, “Information System Activity Review,” undated, showed the following: 1) There shall be a formal documented process which at minimum will include a) Define who will review records of activity b) Define what activity is significant c) Define which activity records need to be archived and for what period of time d) Define what activity constitutes a security incident to be reported e) Define procedures for preserving records of significance activity f) Workforce members should not monitor, or review activity related to their own account g) The HIPAA (Health Insurance Portability and Accountability Act of 1996) Security Officer shall be responsible for reviewing results of information system activity review reports h) The HIPAA Security Officer shall be responsible for enforcing this policy i) All data collected and/or used as part of the Risk Management policy shall be maintained by the organization for a period of 7 years. 2) The policy showed the following information shall be provided to or collected by the HIPAA Security Officer on a monthly basis: a) Security audit logs b) Access reports c) Security incident tracking reports 3) The policy showed the HIPAA Security Officer shall review and study the reports and contact the appropriate individual for any questions, concerns or identified trends. 4) The policy showed the HIPAA Security Officer shall document findings from the monthly review and determine action plans as appropriate. B. During an interview on 05/04/2026 at 3:06 PM, the Information System Director (also HIPAA Security Officer) and Health Information Manager stated there was no evidence the audits and monitoring of the information system activity and required elements were being done, and documentation maintained.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 31039 Based on review of wrong person medication errors for 05/01/25 through 04/30/26, review of clinical records and interview, it was determined the facility failed to maintain accurate records in that one (#2) of two (#1 and #2) incidents of a wrong person medication error were not documented in the chart of the patient that received the medication in error. By not documenting the medication errors, the facility was not keeping an accurate record of the patient’s course of treatment and outcomes, which is essential for planning and delivering future care of the patient. The failed practice had the likelihood to affect all patients that are treated at the facility. Findings follow: A. Review of medication errors for wrong person medication errors showed Incident #2 the patient received Metronidazole 2000 milligram by mouth that was intended for another patient. B. Review of clinical record for Incident #2 showed there was no documentation in the patient’s medical record the patient received Metronidazole 2000 milligram by mouth in error, if the doctor was notified, and what course of treatment was to proceed the error. C. During an interview on 05/05/2026 at 10:13 AM, the Director of Pharmacy verified the findings at A. and B.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 48468 Based on observation, review of National Fire Protection Association (NFPA) guidelines and interview, it was determined the facility failed to prevent the likelihood of the spread of fire and smoke in the respiratory storage closet in that was a hole in fire wall with wires passing through. The failed practice placed patients at risk of fire and/or smoke spreading. The failed practice had the likelihood to affect all patients in the facility. The findings will follow: A. Review of the NFPA 101 guidelines showed, “Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a smoke partition shall be protected by a system or material that is capable of limiting the transfer of smoke.” B. On March 11, 2024, at 11:18 a.m., observation showed the respiratory storage closet had a hole in the fire wall with cables passing through the hole. There was no material protecting the hole to prevent fire and/or smoke passing through the hole. C. The findings of B were confirmed in an interview with the Administrator on March 11, 2024 at 11:18 a.m.”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 50014 Based on policy review, observation, and interview, it was determined that the physical environment was not maintained as a safe and functional environment throughout Shook Hall and North Hall of the facility to avoid sources and transmission of infection in that: A.Throughout Shook Hall showed: 1.Storage rooms with black substance on ceiling tiles. 2.Storage rooms with water stains on ceiling tiles. 3.Storage rooms with dust on clean supplies. 4.Storage rooms with holes in the walls. 5.Clean patient supplies were stored alongside dirty cleaning supplies. 6.Clean patient supplies stored with black substance on ceiling tiles. 7.Clean patient supplies stored in hallway with active construction. B.North Hall showed uncontained construction. The failed practice had the likelihood to cause the spread and transmission of infection to all staff and patients in the facility. The failed practice had the likelihood to affect all patients admitted to the facility. See C1208 for details.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50014 Based on policy review, observation, and interview, it was determined that the physical environment was not maintained as a safe and functional environment throughout Shook Hall and North Hall of the facility to avoid sources and transmission of infection in that: A. Throughout Shook Hall showed: 1. Storage rooms with black substance on ceiling tiles. 2. Storage rooms with water stains on ceiling tiles. 3. Storage rooms with dust on clean supplies. 4. Storage rooms with holes in the walls. 5. Clean patient supplies were stored alongside dirty cleaning supplies. 6. Clean patient supplies stored with black substance on ceiling tiles. 7. Clean patient supplies stored in hallway with active construction. B. North Hall showed uncontained construction. The failed practice had the likelihood to cause the spread and transmission of infection to all staff and patients in the facility. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow: A. Review of Policy and Procedure “Infection Prevention and Control Program” dated 5/25/23 showed the following: 1) The Infection Preventionist and the Infection a Prevention and Control Committee are responsible for identifying, investigating, reporting, preventing, and controlling infections and communicable diseases through the maintenance of a sanitary hospital environment and the development and implementation of infection prevention and control measures related to hospital staff. 2) The Infection Preventionist and the Infection a Prevention and Control Committee are responsible for conducting surveillance within the hospital on a wide basis to identify infectious risks or communicable disease problems at any location or department. B. Review of Policy and Procedure “Sanitary Environment Policy,” dated 8/23/23 showed all areas of the hospital must be clean and sanitary. This includes all hospital units/departments, campuses, and off-site locations. C. Review of the “Infection Control Risk Assessment 2.0 Matrix of Precautions for Construction, Renovation and Operations Table 5 - Minimum Required Infection Control Precautions by Class, Before and During Work Activity” provided by the architects of the construction project on 2/7/2024 at 1:33 PM, showed that: 1) Construct and complete critical barriers meeting NFPA 241 requirements including: Barriers must extend to the ceiling or, if ceiling tile is removed, to the deck above, and all penetrations through the barrier shall meet the appropriate fire rating requirements. 2) All (plastic or hard) barrier construction activities must be completed in a manner that prevents dust release. Plastic barriers must be effectively affixed to ground and ceiling and secure from movement or damage. Apply tape that will not leave a residue to seal gaps between barriers, ceiling, or floor. 3) Seal all penetrations in containment barriers, including floors and ceiling, used approved materials (UL schedule firestop if applicable for barrier type). 4) Containment units or environmental containment units (ECUs) approved for Class IV precautions in small areas totally contained by the unit and that have HEPA-filtered exhaust air. 5) Worker clothing must be clean and free of visible dust before leaving the work area. HEPA vacuuming of clothing or use of cover suits is acceptable. 6) Workers must wear shoe covers prior to entry into the work area. Shoe covers must be changed prior to exiting the anteroom to the occupied space (non-work area). Damaged shoe covers must be immediately changed. 7) Install an adhesive (dust collection) mat at entrance of contained work area based on facility policy. Adhesive mats must be changed routinely and when visibly soiled. Consider collection of particulate data during work to monitor and ensure that contaminates do not enter the occupied spaces. Routine collection of particulate samples may be used to verify HEPA filtration efficiencies. D. During an interview on 1/31/2024 at 3:00 PM, the Chief Executive Office (CEO) and Infection Control Preventionist confirmed A-C. E. Observation on 1/31/2024 at 10:15 AM showed the following: 1. Throughout Shook Hall showed: a) Storage rooms with black substance on ceiling tiles. b) Storage rooms with water stains on ceiling tiles. c) Storage rooms with dust on clean supplies. d) Storage rooms with holes in the wall. e) Clean patient supplies were stored alongside dirty cleaning supplies. d) Clean patient supplies stored with black substance on ceiling tiles. e) Clean patient supplies stored in hallway with active construction. 2. North Hall showed uncontained construction. F. During an interview on 1/31/2024 at 3:00 PM, the CEO and Infection Control Preventionist confirmed the findings in E.”