Mayers 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: 41567 Based on interview, and record review, the facility failed to ensure that emergency medical services were provided in accordance with CFR 489.24, the regulations for the Emergency Medical Treatment and Active Labor Act (EMTALA) when: 1. There was no medical screening evaluation provided for one of 21 sampled patients (Patient 0) (refer to C 2406), and, 2. The medical record was incomplete in regards to a transfer for one of 21 sampled patients (Patient 18) (refer to C 2409).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49418 Based on observation, interview, and record review, Hospital A failed to provide a medical screening examination (MSE), necessary stabilizing treatment, and ambulance transfer for one of 21 sampled patients (Patient 0) experiencing an Emergency Medical Condition (EMC). Patient 0 was Spanish-speaking, 39 weeks 5 days pregnant (full term), and presented to the Emergency Department (ED) experiencing contractions followed by the rupture of membranes (her water broke). Despite Family Member (FM) 0 requesting ambulance transfer to Hospital B (60 miles away), nursing staff informed them that delivery did not appear imminent (about to happen), and that they could drive to Hospital B, and they could call an ambulance on the way if they felt it was necessary. This failure placed Patient 0 and her unborn child at risk for life-threatening medical complications, which could lead to negative and severe clinical outcomes. Findings: The Emergency Medical Treatment and Labor Act (EMTALA - known as the “Patient Anti-Dumping Law”) is a federal law that ensures hospitals participating in Medicare programs provide MSEs, and stabilize patients with an EMC. EMTALA guidelines indicate that a pregnant woman experiencing labor is considered to have an EMC, unless a physician has certified in writing that the individual is in “false,” labor. A review, of the facility’s policy titled, “Triage of Emergency Department (ED) Patients,” dated 2/27/25, indicated that all patients presenting to the ED will be triaged (assessed to determine urgency of need for treatment). The policy directs the Registered Nurses (RNs) to assess every patient in a timely manner, and indicated that any identified special needs would be assisted by addressing language, hearing, learning, or spiritual needs a medical translation service will be used if needed. A review, of the facility’s policy titled, “Interpretation Services,” dated 8/28/19, indicated that the facility provided communication aids to current and prospective patients with limited English proficiency to ensure they had an opportunity to apply for, receive, participate in, or benefit from the services offered by the facility. The policy indicated language interpretation was available 24-hours a day, seven days a week, and could be provided from any touch tone (push-button) phone. A review, of the facility’s policy titled, “EMTALA - Medical Screening Examination and Stabilization,” dated 7/1/24, indicated that an EMTALA obligation was triggered when (1) an individual came to an ED and requested an exam or treatment for a medical condition or, (2) a prudent layperson observer (non-medical person with good judgment) would conclude from the individual’s appearance or behavior that the individual needed an exam or treatment of an EMC. The policy indicated that if a prudent layperson observer believed the individual was experiencing an emergency medical condition (EMC), then an appropriate MSE would be performed. The policy indicated the exam must be completed by an individual qualified to perform such an exam to determine whether an EMC existed or, for a pregnant woman having contractions, if the woman was in labor and if the treatment requested was explicitly for an EMC. The policy indicated, that if an EMC is determined to exist, the individual will be provided necessary stabilizing treatment. A review, of the facility’s policy titled, “EMTALA Transfer Policy,” dated 10/29/24, indicated that a woman in labor who requested a transfer to another facility may not be discharged against medical advice to go to the other facility. The policy indicated the risks associated with leaving must be thoroughly explained to the patient and documented. If the patient insisted on leaving to go to another facility, the facility should take all reasonable steps to obtain the patient’s request in writing and take all reasonable steps to have the patient transported using qualified personnel and transportation equipment. The policy indicated, that transporting a woman in labor by privately-owned vehicle is not an appropriate form of transportation. The policy indicated that a woman who is in labor is considered stabilized only after she has been delivered of the child and the placenta. A review, of a facility’s policy titled, “Childbirth and Maternal Care in the Emergency Department,” dated 6/26/24, indicated that a pregnant patients who presented to the ED where delivery was imminent would be cared for by qualified staff. After delivery and stabilization of mother and infant, an attempt would be made to transfer mother and infant to another facility for admission and continuing care. The policy indicated the procedure for “Pregnancy in Labor” was as follows: 1. Initial examination would be conducted immediately by the ED attending provider. 2. After MSE and consultation with the Obstetrician (OB, a physician who specializes in delivering infants) or private provider, the patient may be transferred to another facility that provided OB services if the transfer was determined safe. 3. If delivery was imminent, delivery will occur in the Emergency Department (ED). During a concurrent observational tour of the ED, and interview, with the ED Manager (EDM) on 6/3/25 at 11:35 am, it was observed that the ED had one triage room, and six patient rooms or “bays.” EDM stated, that Room 6 was typically used for “fast track issues,” (non-life-threatening), and for Obstetrical/Gynecological (OB/GYN - OB related to care of pregnancy, deliver and after birth, GYN related to care of female reproductive system) issues. Observations of Room 6 indicated, a bed with stirrups for OB/GYN exams and a pediatric (for infants/children) “crash cart” (a mobile storage unit containing medications and equipment for emergency life support). EDM stated there was a larger delivery bed with stirrups for patients in labor and a Panda warmer (provides heat to warm the baby while the pediatric team does an assessment after delivery) in an alcove outside the room that were brought in if delivery was imminent, and those items were observed. During an interview, with Registered Nurse (RN) A on 6/3/25 at 3:21 pm, RN A stated she had worked as a nurse at the facility since 2000. RN A stated she got a call from Admitting Clerk (AC) A on 5/3/25; AC A informed her a pregnant woman was, “here to ask questions,” but was not “signed in.” RN A stated, “If the patient had been signed in, I would have triaged her and brought her back, but she wasn’t.” RN A stated she went to the lobby and found four individuals: Patient 0 (pregnant, having contractions); Family Member (FM) 0 (older female, spoke English and provided translation for the family); FM 1 (older male, driver); and FM 2 (younger male, Patient 0’s partner). RN A stated FM 0 asked if they could “check the patient,” to see if she should go to Hospital B to deliver the baby. RN A stated she informed them that Patient 0 would “have to stay there and deliver,” if Patient 0 signed in, the nurse checked her, and Patient 0 had been more than 4 centimeters (cm - a unit of measure) dilated (scale of 1-10 cm, 10 cm indicating the cervix is completely dilated and ready for delivery). RN A informed them the facility was capable of delivering a baby but that they did not have an OB part of the hospital, Patient 0 would not get an epidural because there wasn’t a Certified Registered Nurse Anesthetist (CRNA - advanced practice nurse who administers an epidural - medication into the spine - for pain relief during labor) on staff, but that pain medication was available. RN A informed them they did not have a surgical department and, “If there are complications, we do not do Cesarean sections (C-sections).” RN A stated, “At that time, I was just informing them of their options” and stated, “I told them what we did have.” RN A stated she excused herself to call Family Nurse Practitioner (FNP) A, the midlevel provider (provides a level of care less than a doctor but can function with significant independence) on duty that morning, who was in the “sleep house,” (on facility property). RN A stated her call woke him. RN A stated she asked how experienced he was delivering babies, and he told her, “I’m not.” RN A stated the family talked in Spanish and then stated they were going to Hospital B. RN A stated Patient 0 stood up to leave and looked “uncomfortable,” but FM 0 was “insistent,” they were leaving. RN A stated she asked who was driving, and if they had a suitable car to get there; FM 1 stated he could drive. RN A stated she did not use translation services “because [Patient 0] wasn’t signed in as a patient.” RN A stated, “They just stopped for a question and wanted me to give them information.” RN A stated she wished she had called Hospital B ahead of time to say they had been here. RN A stated, “I feel that’s the only thing I did wrong.” When asked if RN A told the family they could call an ambulance on the way, RN A stated, “Yes, if they felt the need. I did have that conversation.” RN A also stated there were areas of no cell phone service between hospitals, and she informed them that. During an interview, with Director of Quality (DOQ), and EDM, on 6/3/25 at 3:35 pm, EDM stated, that RN A had worked as an OB Nurse at the facility when they had OB services, and that she “had delivered, I believe, 40 babies before.” DOQ stated, that they last had OB in 2016. DOQ stated, that video existed of the interaction between RN A, and the family but noted the audio was difficult to hear. DOQ stated, that the Director of Safety & Security (DSS) created a translation. DOQ noted that the events of 5/3/25 occurred with AC A’s window open and “AC A is bilingual.” DOQ stated, “I interviewed [AC A] after the fact and noted some pretty extreme translation gaps by [FM 0] of what she heard [RN A] say.” During a phone interview, with Patient 0 using interpretation services on 6/4/25 at 9 am, Patient 0 acknowledged her original birth plan had been to deliver her baby at Hospital B. Patient 0 stated, “I don’t remember,” when asked if she understood any of the conversation at Hospital A on 5/3/25, or if she relied on translation from FM 0. Patient 0 acknowledged, that her water broke inside Hospital A, and that staff were aware. Patient 0 said, “Yes, there was a lady who knew... I think it was a nurse.” When asked if an ambulance had been called during the drive from Hospital A to Hospital B, Patient 0 stated, “Yes.” When asked how far away from Hospital B they were when they called the ambulance, Patient 0 stated, “I really couldn’t tell exactly because I was in really bad shape.” During concurrent interview, with Medical Staff Coordinator (MSC), and employee file review, on 6/5/25 at 10:56 am, MSC stated FNP A’s employee records indicated medical privileges to include obstetrical and gynecological precipitous (happens very quickly) delivery. During an interview, with RN B on 6/5/25 at 4:24 pm, RN B stated when a pregnant woman presents to the ED in labor, nursing staff typically ask questions about prenatal care received, how far along she is, and if her water has broken. RN B stated the patient is typically placed in Room 6, the smaller bed is moved out, and a “TOCO monitor” (tocodynamometer - a device placed on the patient’s abdomen that measures uterine contractions) is placed. RN B stated the larger delivery bed, Panda warmer, and supplies are placed in the room, and the Medical Doctor (MD), Respiratory Therapist (RT), and Nurse Administrator On Call (NAOC) are called. RN B stated the NAOC typically comes to the facility to assist and places calls to get more staff because the ED only staffs two nurses; RN B stated at least one more nurse would be needed. When asked if she would use the translation service for a pregnant Spanish-speaking patient who presented in active labor, RN B stated, “Yes, I always use it.” RN B stated there are three tablets available, and the facility provides the translation line on the tablets. RN B stated she would grab a tablet and the provider, then call the translation line, so the patient only had to give the history once and all team members and patient were clear on the plan. During an interview, with EDM on 6/5/25 at 4:38 pm, EDM stated, that she had spoken with RN A and reviewed the video tape. EDM stated, “In my opinion, after hearing RN A’s account, there’s a fine line between giving information and medical advice.” EDM stated, “I would have said, ‘We need to get you checked in so I can do a full assessment.’ EDM acknowledged, “You can see [in the video] she’s actively in labor.” EDM stated the language line definitely would have been beneficial, but she wasn’t a patient. EDM stated, when we pull in more and more and more resources for someone who isn’t admitted, it gets sticky. Where do we draw the line? EDM stated Patient 0 said she wanted an epidural, and the facility could not provide that; EDM stated she believed that is why they left. During concurrent observation, of the 5/3/25 ED lobby video (Video 1) and ED entrance (Video 2) and interview, with DSS on 6/5/25 at 10:50 am, DSS stated, as a layperson with no medical background, Patient 0 appeared “scared,” and “in pain,” on the videos and that pain “seemed to be increasing,” towards the end of the visit. A. On review of Video 1: (1) Patient 0 appeared to have constant abdominal pain, held her hands to her belly, repeatedly changed positions, and did pursed-lip breathing throughout the encounter. (2) RN A can be heard saying to family: “We don’t have any epidural, we don’t have any anesthesia. If the water breaks, there’s concern for (inaudible). You don’t look like you’re going to have a baby in an hour. Do you want me to call [provider] and see if he can deliver the baby?” (3) As Patient 0 stood to leave, observed her to look down at the front of her pants. FM 0 stated, “Oh, her water broke.” RN A stated, “Oh, it did?” and bent to look at Patient 0’s pants. FM 0 stated, “Right now.” RN A stated, “Ok, ok. Well, I still think it will be quite a while, but (inaudible).” (4) RN A can be heard speaking with AC A after family left: “Even though your water breaks, (inaudible) can go on for multiple hours. It’s not perfect, is it? It’s an hour to get there; you can still drive 80.” (5) DSS reviewed my transcription of the video while watching Video 1 and acknowledged hearing all quotes as written above. B. DSS stated Video 2 did not have audio as there were no speakers outside. On review of Video 2, observed the ED lobby entrance. Observed FM 1 left the facility and returned in a small 4-door car to the driveway outside the ED lobby entrance where he parked but left the car running. Patient 0 and FM 2 left the facility shortly afterward, Patient 0 with hand on FM 2’s shoulder, FM 2 supporting her back with his arm. Patient 0 stopped walking, turned to FM 2, appeared to have a painful contraction, did pursed-lip breathing, bent at the waist, and placed her head on his shoulder. FM 0 left the facility, saw Patient 0, and pointed back to the lobby. A short (inaudible) conversation was had, and they walked to the car. FM 2 placed his coat on the seat before Patient 0 got in the car. During a phone interview, with AC A on 6/6/25 at 10:13 am, AC A stated she was bilingual in English and Spanish and remembered the events of 5/3/25. AC A stated she and FM 0 knew each other outside of the facility and that FM 0 was also bilingual. AC A stated FM 0 asked in Spanish if a nurse could give advice to see if Patient 0 would “make it” to [Hospital B] to have her baby. AC A stated Patient 0 said her contractions started the day before, and Patient 0 had “at least two” contractions during the encounter. AC A stated RN A told them if Patient 0 checked in, “You can’t leave afterwards” adding, “If they want to leave, they could sign an against medical advice (AMA - form acknowledging risks of leaving without medical treatment).” AC A stated RN A explained the facility “didn’t have any equipment for a baby,” and if Patient 0 did need a C-section, “we didn’t have the team.” RN A also stated they had a nurse practitioner and “she could ask if he could deliver.” AC A stated FM 0 “was not directly translating right.” AC A stated FM 0 told Patient 0 in Spanish, “If you stay here, they don’t have anything for you, and you’re going to die.” AC A stated RN A told Patient 0 it was her decision to leave or stay, and FM 0 was “pushing her to leave.” AC A stated the patient seemed hesitant and “wasn’t really answering” FM 0. AC A stated she felt FM 0 knew enough English but that “she was panicking, so I think that’s why she wasn’t translating right.” When asked, AC A acknowledged she did not intervene and tell RN A what FM 0 was translating to Patient 0. AC A stated FM 0 asked, “If we call an ambulance, will they take her?” AC A stated RN A told them no, they (ambulance) would “reroute her here.” AC A stated the family got the car ready, and Patient 0’s water broke at that time. AC A stated RN A told them, “You can still make it to the hospital” and to “be careful of the deer.” AC A stated she believed RN A understood Patient 0’s water broke prior to leaving; RN A said, “Maybe you peed. If it broke, you can still make it.” AC A stated she and RN A talked after the family left about what transpired, noting, “We were hoping she made it out of there.” AC A indicated she did not have medical/nursing experience, but as a layperson, Patient 0 “looked scared to me, like she didn’t know what to do.” AC A stated the family said they were going to call an ambulance on their way over and Patient 0 “didn’t say anything.” A review of Patient 0’s medical records from Hospital B was performed: 1. “ED Physician Notes,” dated 5/3/25 at 5:39 am, indicated Hospital B received a “field call (over the radio) for patient in active labor,” contractions lasting 20 to 30 seconds approximately 3 to 4 minutes apart. The note indicated Patient 0 was a 19 year old who arrived by ambulance and was subsequently seen by MD A (ED physician). The note indicated that Patient 0 was “briefly” seen in the ED and a Labor and Delivery (L&D) nurse and the OB on-call were contacted. The note indicated it did not appear Patient 0 would have “emergent precipitous (happening right now) delivery,” and MD A deemed her stable for transfer to the L&D floor “for optimal delivery team/setting.” The note indicated Patient 0 was transferred to L&D at 5:38 am. 2. “ED Physician Notes,” dated 5/3/25 at 5:58 am, indicated Patient 0 was being “prepped for delivery and OB arrival” when MD A was notified Patient 0 was “ready to deliver.” The note indicated MD A arrived at L&D, Patient 0 “began crowning (baby’s head was showing) with eventual delivery after one push.” The note indicated the baby was delivered without complication. 3. “History and Physical,” dated 5/3/25 at 8:56 am, indicated Patient 0 was accompanied by FM 0 and FM 2. Social History indicated Patient 0 was born in California, grew up in Mexico, and had been living back in the area for approximately the last year. 4. “Physician Note,” dated 5/4/25 at 9:25 am, indicated Patient 0 was “doing well” on day after vaginal delivery without complications. The note indicated Patient 0 had an “episode of hypotension (low blood pressure) and borderline loss of consciousness approximately an hour after the delivery.” Discharge of Patient 0 was anticipated for the next day (5/5/25) but she needed to stay 48 hours “since Group-B Streptococcus (GBS - common bacteria carried in the lower genital tract of pregnant women that can be passed to baby, leading to serious infection) status is unknown.” 5. “Discharge Summary,” dated 5/5/25 at 8:43 am, indicated Patient 0 initially went to Hospital A where she was told that “she could not deliver there,” and that she needed to “immediately go to a hospital that can deliver her baby.” The note indicated Patient 0’s water broke at Hospital A “less than 2 hours,” before delivery, and Patient 0 was “complete and starting to crown,” upon arrival to L&D at Hospital B. Patient 0’s urine culture at Hospital B was positive for Escherichia coli (E. coli - bacterial urinary tract infection that can increase the risk of early delivery, low birth weight, and stillbirth), “treated with antibiotics during pregnancy.” Hospital A failed to document the encounter with Patient 0 who presented with an EMC (active labor), nor did staff certify in writing that Patient 0 did not have an EMC per EMTALA guidelines. Translation services were not provided per facility’s policy for a Spanish-speaking prospective patient, and it is unclear if Patient 0 and family could make an informed decision about the risks associated with leaving the facility. RN A, and FNP A, failed to provide an MSE and necessary stabilizing treatment to Patient 0. Neither an OB physician, or FNP A’s supervising physician, were consulted. The facility failed to provide ambulance transfer per facility policy and upon request by family members.”

“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: 41567 Based on interview, and record review, the facility failed to ensure that the transfer process was completely documented in the medical record for one of 21 sampled patients (Patient 18), as evidenced by the inability to produce an informed consent form for a transfer to another facility. This failure had the potential for Patient 18 to be uninformed as to risks and consequences associated with their transfer which could lead to negative clinical outcomes. Findings: A review, of the facility’s policy titled, “Transfer of Patients via Ambulance,” effective 5/30/19, indicated that the process of transferring a patient included obtaining the patient’s signature on appropriate EMTALA (Emergency Medical Treatment and Active Labor Act) consent forms. A review, of Patient 18’s medical record indicated that he had diagnoses that included pneumothorax (a collapsed lung), and a right hip injury. An Emergency Department (ED) Provider Note, dated 5/8/25 at 2:32 am, by Family Nurse Practitioner (FNP) A, indicated that Patient 18 required a higher level of care and would be transferred out from the facility. A review, of Patient 18’s EMTALA Note, by FNP A dated 5/8/25 at 2:46 am, indicated that consent for transfer had been obtained. A review, of Patient 18’s Provider’s Orders, by FNP A dated 5/8/25 at 5:32 am, directed that Patient 18 was to be transferred to another facility. During an interview, on 6/5/25 at 1:38 pm, the ED Manager (EDM) stated, that she was unable find written consent for the transfer in Patient 18’s medical record, and explained that consent forms are filled out on an electrical tablet, including patient signatures, and if the form was missing, it was because it had not been completed. The EDM affirmed, that consent is necessary, and stated that without it, the facility did not have proof that permission was given for transfer, or that the risks and benefits of the transfer had been explained fully to the patient.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by the failure to include strategies for an identified risk. This affected all patients and could result in the facility not being prepared for a mass casualty event. Findings: During record review and interview with the Staff on 10/8/24, the EPP was reviewed. At 3:12 p.m., the facilities Hazardous Risk Assessment listed mass casualty event as a top risk for the facility. The Facility’s EPP failed to include strategies that addressed mass casualty events. Upon interview, Staff C acknowledged that the facility’s EPP failed to include a policy and procedure that addressed mass casualty events.”

“K3 BUILDING: 01 Emergency Department at Main Hospital-Fall River Mills Campus K6 PLAN APPROVAL: 2019 K7 SURVEY UNDER: 2012 NEW K12 TYPE OF STRUCTURE: ONE STORY TYPE II CONSTRUCTION, FULLY SPRINKLER. K3 BUILDING: 01 - Main Hospital Fall River Mills Campus K6 PLAN APPROVAL: 1972 K7 SURVEY UNDER: 2012 EXISTING K12 TYPE OF STRUCTURE: ONE STORY TYPE V CONSTRUCTION, FULLY SPRINKLER. The following reflects the findings of the California Department of Public Health, during a recertification Life Safety Code Survey. The findings are in accordance with 42 Code of Federal Regulations (CFR) §485.623(c)(d)(e) Critical Access Hospitals (CAHs), National Fire Protection Association (NFPA) 101 - Life Safety Code, 2012 Edition, and NFPA 99 - Health Care Facilities Code, 2012 Edition. CENSUS: 5”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls. This affected the Main hospital and the Emergency department, and could result in the spread of smoke in the event of a fire. Findings: During a tour of the facility and interview with Staff on 10/8/24, the walls and ceilings were observed. 1. At 11:06 a.m., an approximately quarter inch penetration was observed in the wall across from the lockers in the men’s locker room in the Emergency Departments imaging area. Upon interview, Staff B stated that the penetration appeared to be from a wall anchor. 2. At 11:59 a.m., an approximately one foot by two-and-a-half-foot penetration was observed in the South wall in the water filler closet on the outside of the surgical wing. Upon interview, Staff B stated that it looks like the drywall was cut out to access the ventilation ducts.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 43380 Based on observation, record review and interview, the facility failed to maintain the emergency battery backup lights. This was evidenced by the failure to document annual testing. This affected the Emergency Department and the Main Hospital, and could result in a failure to provide backup lighting in the event of an emergency. NFPA 101: Life Safety Code, 2012 Edition 19.2.9/18.2.9 Emergency Lighting. 19.2.9.1/18.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9. 7.9 Emergency Lighting. 7.9.3 Periodic Testing of Emergency Lighting Equipment. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11/ 2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. Findings: During a tour of the facility, record review and interview with Staff on 10/8/24, the emergency lighting was observed and tested. At 2:11 p.m., the testing records for the battery backup emergency lights were requested for emergency rooms, labs, operating rooms and the outpatient medical/recover area. The facility failed to provide documentation that an annual 90 minute functional test had been conducted on the emergency battery backup lights within the last 12 months. Upon interview, Staff D acknowledged that there was no annual test record available for review.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 43380 Based on observation, record review and interview, the facility failed to maintain the battery backup exit signs. This was evidenced by the failure to document annual testing. This affected the Emergency Department and the Main Hospital, and could result in a failure of the illuminated exit signs in the event of an emergency. NFPA 101: Life Safety Code, 2012 Edition 19.2.10/18.2.10 Marking of Means of Egress. 19.2.10.1/18.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. 7.10.9 Testing and Maintenance. 7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3. 7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3. 7.9.3 Periodic Testing of Emergency Lighting Equipment. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11/ 2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. Findings: During a tour of the facility, record review and interview with Staff on 10/8/24, the battery backup exit signs were observed and testing and inspection records were requested. At 2:12 p.m., the testing records for the battery backup exit signs were requested. The facility failed to provide documentation that the annual 90 minute functional test had been conducted on the exit signs within the last 12 months throughout the facility. Upon interview, Staff D acknowledged that there was no annual test record available for review.”

“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: 43380 Based on observation and interview, the facility failed to maintain the fire sprinkler system. This was evidenced by missing signage for the sprinkler valves. This affected Emergency Department, and could result in delay and confusion of identifying the fire sprinkler valves that serves the facility. NFPA 101: Life Safety Code, 2012 Edition 18.3.5 Extinguishment Requirements. 18.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 18.3.5.5. 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.1 Automatic Sprinklers. 9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition 6.7.4 * Identification of Valves. 6.7.4.1 All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. 6.7.4.2 The identification sign shall be secured with corrosion-resistant wire, chain, or other approved means. 6.7.4.3 The control valve sign shall identify the portion of the building served. Findings: During a tour of the facility and interview with Staff on 10/8/24, the fire sprinkler system was observed. At 10:22 a.m., two valves were observed on the fire sprinkler drainpipe on the underside of the Main Entry Canopy outside of the Main Lobby in the Emergency Department. Both valves were missing signage that indicated their purpose. Upon interview, Staff D acknowledged that the valves were missing identification signs.”

“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: 43380 Based on observation, record review and interview, the facility failed to maintain the fire sprinkler system. This was evidenced by missing inspection records, sprinklers covered in cobwebs and obstructed sprinkler heads. This affected the Main Hospital and the Emergency Department, and could result in the malfunction of the sprinklers in the event of a fire. NFPA 101 Life Safety Code, 2012 edition 19.3.5.1/18.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.1 Automatic Sprinklers. 9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition 8.10.6.3 * Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. 8.10.6.3.1 Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.10.6.3. NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 6.2 Inspection. 6.2.2 Gauges. 6.2.2.2 Gauges on dry, preaction, and deluge valves shall be inspected weekly to ensure that normal air and water pressure are being maintained. Findings: During a tour of the facility, record review and interview with Staff on 10/8/24, the automatic sprinkler system was observed. 1. At 10:25 a.m., two of four fire sprinkler heads under the ambulance canopy outside of the ambulance bay doors in the Emergency Department were observed with cobwebs covering the sensing bulbs, frames, and deflectors. Upon interview, Staff B acknowledged that the sprinklers were covered in cobwebs. 2. At 11:19 a.m., the pharmacy storage/server closet across from the pharmacy was observed. Items were stored on top of the shelving unit on the back wall of the closet at approximately 11 inches below the single sprinkler in the ceiling of the closet. Upon interview, Staff B acknowledged that the sprinkler was obstructed. 3. At 11:29 a.m., the respiratory storage closet across from the Director of Clinical Services Office was observed. A box of disposable towel was stored on the top shelf at approximately five inches below the single sprinkler in the ceiling of the closet. Upon interview, Staff D acknowledged that the sprinkler was obstructed. 4. At 4:27 p.m., the inspection and maintenance records for the dry pipe fire sprinkler system in the emergency department expansion were requested. The facility failed to provide documentation that a weekly visual inspection was being conducted on the dry pipe fire sprinkler system. Upon interview, Staff D acknowledged that there were no weekly inspection records available for review.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by a free-standing fire extinguisher. This affected the Emergency Department, and could result in damage to the fire extinguisher and a delay in responding to a fire in the event of an emergency. NFPA 101: Life Safety Code, 2012 Edition 18.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1 9.7.4.1 * Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10: Standard for Portable Fire Extinguishers, 2010 Edition 6.1.3.8 Installation Height. 6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). Findings: During a tour of the facility and interview with Staff on 10/8/24, the fire extinguishers were observed. At 10:26 a.m., a red ABC fire extinguisher was observed freestanding on the ground along the South wall of the electrical room next to the ambulance bay door entrance to the Emergency Department. Upon interview, Staff D acknowledged that the fire extinguisher was free standing and not mounted on a wall in the room.”

“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: 43380 Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch. This affected the Main Hospital, and could result in the spread of fire or smoke in the event of a fire. Findings: During a tour of the facility and interview with Staff on 10/8/24, the corridor doors were observed. 1. At 11:21 a.m., the corridor door to the pharmacy storage/server closet across from the pharmacy failed to latch when tested. Upon interview, Staff A stated that the door was scheduled to be replaced. 2. At 12:05 p.m., the corridor door to the shower room next to Patient Room 107 failed to latch when tested. Upon interview, Staff D acknowledged that the door failed to latch.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 43380 Based on record review and interview, the facility failed to maintain the integrity of the heating, ventilation, and air-conditioning (HVAC) system. This was evidenced by the failure to identify the location of the fire/smoke dampers throughout the facility. This affected the Emergency Department and the Main Hospital, and could result in the spread of smoke in the event of a fire. NFPA 101: Life Safety Code, 2012 Edition 19.5.2/18.5.2 Heating, Ventilating, and Air-Conditioning. 19.5.2.1/18.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ’ s specifications, unless otherwise modified by 19.5.2.2. 9.2 Heating, Ventilating, and Air-Conditioning. 9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 90A: Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition 5.4.8 Maintenance. 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80: Standard for Fire Doors and Other Opening Protectives, 2010 Edition 19.3.4 Documentation. All inspections and testing shall be documented, indicating the location of the fire damper, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. 19.4 * Periodic Inspection and Testing. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. Findings: During record review and interview with Staff on 10/8/24, the fire dampers inspection records were reviewed. At 1:51 p.m., a document titled, “SNF Fire Damper Inspection Fall River Campus” was reviewed. The inspection report dated 11/14/23 indicated the facility had 41 fire dampers. The document listed the damper numbers (1 through 41), damper passed or failed, a functional inspections, and the cleanliness inspection. At the bottom of the second page, under the comment section, it stated that the fusible links for dampers 5, 12, 23, 27, and 35 were replaced at time of inspection. The document failed to include the locations of each dampers. Upon interview, Staff D acknowledged that the damper location was not included in the documentation.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the vacuum and piped medical gas systems. This was evidenced by an obstructed and silenced medical gas master alarm panel. This affected the emergency department and could result in delayed access to the panel in the event of an emergency. NFPA 99: Health Care Facilities Code, 2012 Edition 5.1.9.2 * Master Alarms. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system. 5.1.9.2.1 The master alarm system shall consist of two or more alarm panels located in at least two separate locations, as follows: (2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location). Findings: During a tour of the facility and interview with Staff on 10/8/24, the gas and vacuum piped medical gas system was observed. 1. At 10:52 a.m., the Total Alert master alarm panel for the Emergency Department expansion was observed. The mute button indicated the audible panel alarm was silenced. Upon interview, Staff A stated that a sensor had gone bad in the system and required replacement. The part was ordered, and their vendor was waiting for it so they could schedule the replacement. 2. At 10:54 a.m., the Total Alert master alarm panel for the Emergency Department expansion was observed. A printer and a 50-gallon wheeled document shredding container were observed obstructing access to the panel located at the Nurse Station in the Emergency Department. Upon interview, Staff A and Staff B acknowledged that the panel was obstructed.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 43380 Based on observation, record review and interview, the facility failed to maintain the isolated power system equipment. This was evidenced by the failure to provide testing documentation. This affected the Main Hospital, and could result in the malfunction of the line isolation monitoring equipment. NFPA 99: Health Care Facilities Code, 2012 Edition 6.3.2.6.3.6 A reliable test switch shall be mounted on the line isolation monitor to test its capability to operate (i.e., cause the alarms to operate and the meter to indicate in the “alarm on” zone). This switch shall transfer the grounding connection of the line isolation monitor from the reference grounding point to a test impedance arrangement connected across the isolated line; the test impedance(s) shall be of the appropriate magnitude to produce a meter reading corresponding to the rated total hazard current at the nominal line voltage, or to a lesser alarm hazard current if the line isolation monitor is so rated. The operation of this switch shall break the grounding connection of the line isolation monitor to the reference grounding point before transferring this grounding connector to the test impedance(s), so that making this test will not add to the hazard of a system in actual use; nor will the test include the effect of the line-to-ground stray impedance of the system. The test switch shall be of a self-restoring type. Findings: During a tour of the facility, record review and interview with Staff on 10/8/24, the operating rooms were observed. At 2:04 p.m., The facility was observed with two line isolation monitor (LIM) units outside of each Operating Rooms. Both LIM units were equipped with a test switch that activates both visual and audible alarms when tested. The inspection and testing records for the LIM units for both Operating Rooms were requested. The facility failed to provide testing records for the LIM system in the operating rooms. Upon interview, Staff B and Staff D stated they were not aware of the requirement.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 43380 Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the use of extension cords and suspended power strips. This affected the Main Hospital and could result in an increased risk of fire. NFPA 101 Life Safety Code, 2012 Edition 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1 Utilities. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70 National Electrical Code, 2011 Edition 400.8 Uses Not Permitted. unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage 400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals. Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable. Findings: During a tour of the facility and interview with Staff on 10/8/24, the electrical equipment was observed. 1. At 11:09 a.m., a white power strip was observed suspended approximately four inches above the floor under the Patient Access Manager’s desk in the Patient Finance and Registration Office. The Power Strip was powering computer and phone equipment. Upon interview, Staff B acknowledged the suspended power strip. 2. At 11:12 a.m., a white power strip was observed suspended approximately eight inches above the floor, near a small black refrigerator in the Lab office. The power strip was powering the refrigerator and a coffee pot. Upon interview, Staff B acknowledged the suspended power strip. 3. At 11:27 a.m., an extension cord was observed powering a microwave behind the Medical Staff Services desk in the Quality Office. Upon interview, Staff A acknowledged the extension cord. 4. At 12:10 p.m., a white power strip was observed suspended approximately four inches above the floor, under the Nurses Workstation at Nurse Station 1. The power strip was powering computer and phone equipment. Upon interview, Staff B acknowledged the suspended power strip.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 34975 Based on observation, interview, and facility document review, the facility failed to maintain the kitchen walk-in freezer free of ice build-up. This failure had the potential to result in contamination of food, decrease the quality of food, and pose a fall risk to staff. Findings: During an interview, on 9/23/24 at 3:15 pm, Dietary Services Manager (DSM) stated, that she did weekly kitchen inspections, and the Registered Dietitian (RD) did the monthly kitchen inspections, and these were documented on a sanitation checklist. The DSM’s inspection checklists for the month of August, and September were requested. Also, the RD’s checklists for the past four months were requested. During an observation, in the kitchen on 9/25/24 at 2:37 pm, there was significant ice build-up inside and throughout the walk-in freezer. There was a large icicle over 12-inches in length and one inch thick hanging at the back of the freezer. There was also frost and ice on additional cases and containers of food. In addition, there was ice on the ceiling, the metal food storage racks, and there was thick ice covering the floor. During a consecutive interview, on 9/25/24 at 2:40 pm, DSM stated, that the ice build-up was an ongoing issue. The DSM stated, that she documented the ice build-up consistently on her weekly Kitchen Sanitation Checklist. The DSM stated, that maintenance staff de-frosted the freezer, but the ice come back within a couple of weeks. A review, of the “Kitchen Sanitation Checklist,” completed and signed by DSM on 8/2/24, 8/8/24, 8/16/24, 9/6/24, 9/12/24, and 9/20/24, indicated that the freezer was not free from ice build-up. During an interview, and document review, on 9/25/24 at 2:45 pm, the Facilities/Engineering Supervisor (FES) stated, that he was aware of the ice build-up in the freezer. FES stated, that there was a lot of moisture. FES stated, that the freezer was serviced and provided an invoice from an outside vendor dated 4/12/24, which he confirmed was the last time the freezer was serviced. When FES was asked about the continuous ice build-up despite the service on 4/12/24, FES stated, that he would not contact an outside vendor to service the freezer for ice build-up, only for out of range temperatures. During an interview, on 9/26/24 at 9:30 am, the Director of Operations (DO, DSM Supervisor) stated, that she did not see the sanitation checklists from DSM. During an interview, on 9/26/24 at 9:50 am, the Infection Preventionist (IP) stated, that she did not see the sanitation checklists from DSM. According to the 2022 Federal Food Code, equipment is to be maintained in a proper state of repair.”

“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: 39942 Based on observation, interview, and record review, the facility failed to have complete patient care policies related to three out of six sampled patients (Patients 22, 23, and 25) when: 1. Patient 22 had an incentive spirometer (a device used to encourage taking deep breaths) without a physician’s order, and the policy didn’t indicate whether or not an order was required; 2. Patients 22, 23, and 25 had sedation assessments (an evaluation of the patient’s level of alertness and breath rate) ordered by the Electronic Health Record (EHR) computer system with no documentation done by nursing. The facility had no policy about how to process these orders, or which sedation scales to use; 3. Hospital equipment was stored in patient room closets, and there was no policy about storing items in patient closets. This failure had the potential to negatively impact the patients’ health and well-being which could lead to negative clinical outcomes. Findings: 1. A review, of Patient 22’s EHR indicated, that they were admitted to the facility on 9/22/24. Patient 22’s diagnoses included possible pneumonia (a lung infection), and history of a stroke. Patient 22 required supplemental oxygen, and had orders for nebulized (inhaled mist) medication treatments, but no incentive spirometer order. During a concurrent interview, and observation, on 9/24/24 at 10:40 am, Respiratory Therapy Manager (RTM) confirmed, that Patient 22 had an incentive spirometer at their bedside. RTM stated, that an incentive spirometer given to a patient in the hospital required a physician’s order. A facility policy titled, “Incentive Spirometry (IS),” approved 7/25/19, was reviewed. The policy indicated that an IS was a component of bronchial hygiene (a set of techniques that helped clear mucus and secretions from the airways). IS was indicated for conditions that could have caused pulmonary atelectasis (when all or part of a lung collapsed). The policy did not indicate whether or not to obtain a physician’s order for the device. During an interview, on 9/25/24 at 3:48 pm, the Director of Nursing (DON) confirmed, that the IS policy did not specify whether or not a physician’s order was required, and it was unclear whether or not the facility required a physician’s order. 2. Further review, of Patient 22’s EHR indicated a physician’s order for hydrocodone-acetaminophen (brand name Norco, an opioid pain relieving medication that had the potential to cause drowsiness and slow the breathing rate) tablets every four hours as needed for pain. The EHR showed an order for, “Sedation Assessment High Risk Adult,” to have been performed every one hour for 12-hours, then every two hours for 12-hours, then every four hours. The order read, “Assess for oversedation first 24-hours opioid administration, with new/changed opioid, addition of sedative or episode of respiratory depression, oversedation. When opioids are discontinued assess for oversedation as appropriate.” During a concurrent interview, and record review, on 9/23/24, at 3:35 pm, Registered Nurse (RN) 2 did not locate documentation about the sedation scales for Patient 22. RN 2 stated, that the orders for sedation assessments were automatically populated by the computer system. During a concurrent interview, and record review, on 9/23/24 at 4 pm, RN 1 stated, that the order for Patient 22’s sedation assessments should have been discontinued. RN 1 stated, that nursing usually notified the physician to ask if they would like to discontinue the sedation assessments. If nursing had documented and done the sedation assessments, they would have used the Richmond Agitation Sedation Scale (RASS), a 10-point scale used to determine a patient’s level of agitation and sedation. A review, of Patient 23’s EHR indicated they were originally admitted to the facility on 4/10/24. Patient 23’s diagnoses included dementia (a mental disorder that caused memory loss and confusion), transient ischemic attacks (TIA, a brief episode where blood supply to the brain was cut off), and atrial fibrillation (an irregular heart rhythm). Patient 23’s physician’s orders included Norco tablets every six hours as needed for pain. Patient 23 had sedation scales ordered by the EHR system. During a concurrent interview, and record review, on 9/24/24 at 9:23 am, RN 2 did not locate any sedation assessments or RASS scores documented in Patient 23’s EHR. A review, of Patient 25’s EHR indicated they were admitted to the facility on 3/30/24. Patient 25’s diagnoses included right pelvic fracture, high blood pressure, and depression. Patient 25’s physician’s orders included, Norco tablets every six hours as needed for pain. Patient 25 had sedation assessments ordered by the EHR system on 3/31/24. During a concurrent interview, and record review, on 9/25/24 at 3:51 pm, the DON did not locate any sedation assessments documented in Patient 25’s EHR. DON stated, that the facility did not have a policy about sedation scales, or the sedation assessment orders. 3. During a concurrent observation, and interview, on 9/23/24 at 2 pm, in unoccupied patient Room 108, RN 2 confirmed there were items such as vinyl-covered cushions, a walker and a cane stored in the patient closet. During a concurrent observation, and interview, on 9/23/24 at 2:01 pm, in unoccupied Room 106, the Housekeeper confirmed there were items stored in the patient closet. There was also dirt and sawdust on the floor of the closet. During a concurrent interview, and record review, on 9/23/24 at 2:45 pm, the DON stated, that the facility did not have a policy about storage in patient closets.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 26917 Based on observation, interview, and record review, the hospital failed to develop and implement policies as evidence by: 1.The hospital did not adequately maintain and update the content lists for emergency crash carts, which could potentially lead to discrepancies between the actual contents of the carts and the documented lists. This lack of accurate information may pose risks during emergencies, as healthcare providers rely on these lists to quickly locate and administer necessary medications and supplies. 2.The hospital did not consistently follow best practices for medication labeling, as evidenced by the absence of dates on partially used insulin vials and the lack of dating for a medication removed from its overwrap. Proper labeling of medications, including the date of opening, is essential for ensuring medication safety, maintaining potency, and reducing the risk of contamination. 3.The hospital lacked a dedicated medication administration policy, which is essential for establishing standardized practices and ensuring consistent, safe medication administration across all departments. The absence of such a policy may contribute to variability in medication management practices, potentially compromising patient safety and quality of care. 4 & 5. The hospital did not adequately maintain medication supplies that have not become out of date. Removing outdated medications from patient care areas is essential for ensuring medication safety, maintaining potency, and reducing the risk of contamination. Findings: 1. During an observation, on 9/24/24 on the medical-surgical floor, an adult crash cart was present. The content list indicated approval by PNT in 2018; however, the policy included an updated content list with additions not found on the 2018 list, such as flumazenil 1 miligram (mg) per 10 mililiters (mL), nitroglycerin 50 mg per D5W 250 mL, and epinephrine 4 mg per 250 mL. During an observation, on 9/24/24 at 10:30 AM, in the surgery department, an emergency crash cart was present. However, the 2018 content list was found on the outside of the cart, while the updated 2021 content list was not visible. This raises concerns about the accuracy of the information readily available to healthcare providers during emergencies. During an interview, on 9/24/24 with the Director of Pharmacy at 10 am, he acknowledged that the 2018 content list for the emergency crash cart was outdated and had been updated in 2021. He further explained that several changes had been made to the list, but the old content list had not been properly updated, resulting in some discrepancies. During an observation, on 9/24/24 at 10:45 am, in the outpatient department, an emergency crash cart was present, but there was no content list on the outside of the cart. This poses a potential risk, as healthcare providers may not have immediate access to the information about the medications and supplies contained within the cart, which could lead to delays in treatment or errors during emergencies. An accurate and up-to-date inventory of the emergency crash cart is critical to patient safety and effective emergency care. Inaccurate content lists can lead to missing essential medications or supplies, causing delays in treatment or adverse outcomes. Miscommunication may arise when healthcare providers expect certain items to be present but find outdated or incorrect supplies, increasing the risk of errors 2. During an observation, on 9/24/24 at 11 am, at the medical-surgical department’s medication room, two findings were noted: partially used insulin that was not labeled with an expiration date, and an opened Advair medication that was stored outside of its overwrap without a dated label. These observations raise concerns about medication safety and the potential for decreased efficacy, or contamination. A review, on 9/24/24 of the hospital policy titled, “Use of Multidose Vials,” indicated that the expiration date for multidose vials should follow the manufacturer’s recommended date listed on the vial. The policy further stated, that once a vial has been accessed, it should be disposed of after 28 days, assuming no visible contamination is present and standard precautions have been taken during handling. During an interview, on 9/24/24 at 11 am, with the Director of Pharmacy, he mentioned that there was no specific policy on dating and labeling inhalers once they have been opened or removed from their overwrap. He acknowledged the importance of this practice and committed to adding these guidelines to the medication storage policy to ensure the safe use of medications within the facility. During an interview, on 9/24/24 at 11 am, with the Director of Pharmacy, he acknowledged that opened insulin should be dated upon opening and is typically good for 28-days. He also confirmed that Advair should be dated once opened and is generally stable for 45-days. The Director recognized that these labeling practices were not followed in the observed instances and committed to addressing the issue and ensuring proper medication labeling practices moving forward. 3. During an interview, on 9/24/24 at 9:20 am, with the Director of Pharmacy, he stated that there is no specific, titled policy for medication administration within the hospital. This absence of a formal, documented policy may pose challenges in ensuring consistent and standardized practices for medication management across the facility. A review of the hospital’s policies revealed that there was no specific policy dedicated to medication administration. The absence of a clear, standardized medication administration policy may hinder the hospital’s ability to promote consistent practices and ensure patient safety in this critical aspect of care. 40204 4. On 9/25/24 at 3:30 pm, during a concurrent observation, and interview, of the “Mobile Clinic” (MC) with Medical Assistant 41 (MA41), an expired flu testing solution was found to have expired on 7/24 (July 2024). When asked MA41 stated another employee had, “told me it was still ok to use.” MA41 later explained that the employee responsible for removing expired items, “doesn’t work here any more.” MA41 discarded the test solution from the patient care area. Observations continued with MA41 in Exam Room 2 where an emergency supply box was found to have four expired containers of Diphenhydramine 25 mg per 10 cubic centimeters (weight and measure). MA41 stated, “I didn’t know those were expired,” and discarded them from the exam room. Physician Assistant-Certified 41 (PAC41) was also present and verified the items were out of date, and removed from the patient care area so they would not be used. 39942 5. During a concurrent observation, and interview, on 9/26/24 at 8:25 am, in the Rural Health Clinic procedure room, Telemedicine Coordinator (TMC) opened the emergency kit (a box filled with emergency supplies). The kit contained one Epipen (epinephrine-a medication used to treat life-threatening allergic reactions) 0.3 mg, and one EpiPen 0.15 mg. TMC confirmed the EpiPen 0.3 mg syringe had a printed expiration date of 6/2024, and the EpiPen 0.15 mg syringe had a printed expiration date of 7/24. During a concurrent observation, and interview, on 9/26/24 at 8:35 am, TMC confirmed there were five multi-dose vials of Moderna brand COVID booster, lot number AS7642B, with no printed expiration date. A review, of the Moderna vaccine Vial Expiration Checker, found online at: https://modernacovid19global.com/en-US/vial-lookup, indicated a field in which to enter the vaccine’s lot number. When the lot number AS7642B, was entered in the search field, the page displayed the message, “Expiration date Oct. 13, 2023. Your vaccine has expired.” A facility policy titled, “Outdated Medications - Clinic,” approved 5/31/23, was reviewed. The policy’s purpose was to ensure outdated pharmaceuticals were not distributed to patients of the Rural Health Center. Outdated medications found during inspection were to be removed from stock and sequestered (isolated) and removed from the medication room site.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 34975 Based on interview, and facility document review, the facility failed to ensure menus for in-patient diets were in accordance with recognized dietary practices, as evidence by: 1. Lack of a comprehensive nutritional analysis of the patient menu for regular and therapeutic diets; 2. Lack of a basic nutritional analysis for the patient disaster menu; and 3. Lack of a disaster menu for Renal diets (a therapeutic diet designed for those with kidney failure). The failure to ensure the nutritional needs of patients were met had the potential to result in worsening of patient prognosis which could lead to negative clinical outcomes. Findings: 1. Review of the “Fall Menus Week: 1” signed by the Registered Dietician (RD), indicated available patient diets included Regular, Mechanical Soft (a texture modified diet that consists of foods that require minimal chewing), Puree (a texture modified diet that consists of smooth foods that do not require chewing), 2 Gram Sodium (a therapeutic diet that limits the amount of sodium to 2 grams per day), Low Fat/Low Cholesterol (a therapeutic diet that limits the amount of fat and cholesterol), Consistent Carbohydrate (CCHO; a therapeutic diet to help manage blood sugar with consistent levels of carbohydrate per meal). During an interview, and concurrent document review, on 9/25/24 at 10:43 am, two documents titled “Menu Template Nutrition Summary,” showed a 28-day average nutrient analysis for the Spring cycle CCHO and Regular menus. RD confirmed the only nutrient analysis available were for the CCHO and the Regular diet which showed nutrients for a 28-day average. RD confirmed the facility did not have a nutrient breakdown of the menu for each available patient diet and for less than a 28-day average (the average length of stay was 4.0 days). RD confirmed she was not able to determine whether the patient menus met the nutritional needs of the patients because there was not a nutrient analysis, as related to the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences, for less than a 28-day average for the available patient diets. RD stated the company who provided the menus could not provide a nutrient analysis for some of the therapeutic diets and it was very difficult to get any nutrient analysis from them. RD also explained the Diet Manual (a resource which reflects information for the diets served) from the company who provided the menus was not being used and an older Diet Manual from a different company was in use. During an interview, on 9/26/24 at 10:40 am, the Director of Nursing (DON) stated, that the average length of stay was 4.0 for the past six months. Review of the undated “Position Description Registered Dietitian,” showed the Dietitian provided consultation to the facility for the purpose of providing nutrition care which will result in optimal health of the patients. The RD will work with the Certified Dietary Manager to meet the nutritional needs of the organization and the Food and Nutrition Services Department. Responsibilities include but are not limited to approves menus. This is a repeat finding from a recertification survey conducted by the Department in 2017, and 2012. 2. Review of the Policy and Procedure titled, “Food & Nutrition in a Disaster Plan Policy # DIA021” revised 8/20/24, showed the Hospital will meet the nutritional needs of patients while sheltered in place, or evacuated to other locations. The Plan showed shelf stable menus for “Regular, Puree, Diabetic, and Low Sodium” diets. During an interview, on 9/24/24 at 10:45 am, the RD stated she was not aware of a nutrient analysis for the disaster menu to show the menu met the nutrient needs of patients. 3. Review of the Policy and Procedure titled, “Food & Nutrition in a Disaster Plan Policy # DIA021” revised 8/20/24, showed the Hospital will meet the nutritional needs of patients while sheltered in place, or evacuated to other locations. The therapeutic menus available according to the disaster plan included “Regular, Puree, Diabetic, and Low Sodium”. During an interview, on 9/24/24 at 10:45 am, the RD confirmed a Renal diet was not part of the disaster plan. During an interview, on 9/25/24 at 10:43 am, RD stated it may not be safe for a patient prescribed a Renal diet, to receive a different diet. RD stated the level of nutrients in the food provided, such as protein, potassium, and phosphorous might need to be adjusted.”

“PATIENT CARE POLICIES CFR(s): These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section and updated as necessary by the CAH. This Standard is not met as evidenced by: 34975 Based on interview, and record review, the facility failed to ensure all policies were reviewed at least biennially (every two years). This failure had the potential for facility staff to follow policies that did not reflect the most current standard of practice, thereby compromising patient care, health and safety which could lead to negative clinical outcomes. Findings: During an interview, and document review, on 9/25/24 at 4:15 pm, the Dietary Services Manager (DSM) provided requested policy and procedures related to issues found in the kitchen (Cross-reference C-914, and C-1208) titled, “Proper Food Handling”, “Cleaning Schedules/Procedures,” “Freezer Storage,” and “Pest Control.” The policy and procedures provided did not have an approval date. The DSM stated, that currently there were no approved policy and procedures for Food and Nutrition Services because they were being updated. The DSM explained, that the unapproved policy and procedures she provided might contain information that was not current. A review of the policy and procedure titled, “Policies & Procedures: Development, Revision & Approval” approved 11/6/23, showed that the [Hospital] develops and continually maintains Policies and Procedures and Policy and Procedure manuals as appropriate to the operation of the facility and associated enterprises. Policies and Procedures are the blueprint for directing all aspects of patient care, employee relations, departmental responsibilities... Each department manager is responsible to develop and maintain departmental Policies and Procedures, which reflect the department’s standards of performance. All Policies and Procedures will be in a standardized format. Policies and Procedures pertaining to the Critical Access Hospital and its associated services... are reviewed and routed through a multidisciplinary Policy and Procedure/Forms Committee which meets on a regular basis.”

“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: 41567 Based on interview, and record review, the facility failed to adequately assess pain relief after interventions for one (Patient 34) of six sampled patients. This failure had the potential to allow Patient 34 to remain in pain and suffer near the end of his life, at a time when he was unable to meaningfully communicate his needs. Findings: A review, of the undated facility policy titled, “Pain Management,” which indicated that emphasis would be placed on improving the outcomes of pain management including comfort, side effects, complications and patient satisfaction. A measure of pain intensity was to be assessed and documented in the electronic medical record, including after each pain management intervention once sufficient time has elapsed for the treatment to reach peak effect (or not greater than one hour after interventions). Pain intensity would be measured using pain scale tools of 0 to 10 with 0 indicating the absence of pain and 10 indicating the worst or most severe pain. All interventions are to be documented and evaluated by reassessment of pain score for effectiveness of the intervention. Patient 34’s medical chart was reviewed. A History and Physical dated 6/18/24, indicated that Patient 34 was admitted with respiratory syncytial virus (RSV, a virus that infects the lungs, throat and nose and can affect breathing), congestion and fever. Patient 34’s medical history included atrial fibrillation (a disorder of the heart that effects its ability to pump normally), chronic kidney disease (decreased functionality of the kidneys, the organs that clean the blood of toxins and waste), chronic obstructive pulmonary disease (a group of inflammatory lung conditions that obstruct airflow and make it hard to breathe), chronic anemia (a long-term condition in which abnormal or insufficient numbers of red blood cells are unable to meet the demands of the bod), Parkinson’s disease (a progressively worsening disorder caused by degeneration of nerve cells in the part of the brain), and dementia (a progressive decline in thinking, behavioral and social skills that affects a person’s ability to function) from previous cerebral vascular accidents (a condition that occurs when blood flow to the brain is interrupted which can lead to damage of brain tissue). A review was made of a discharge summary by Medical Doctor (MD) 1, dated 6/25/24 at 4:01 pm, which indicated Patient 34 had been refusing care, his condition was discussed with his durable power of attorney representative (a person authorized to act on the patient’s behalf when they are unable to communicate), and the decision was made to provide comfort care (a type of medical care focusing on comfort and quality of life for patients near the end of their life) measures until he passed. A review was made of Patient 34’s pain management care plans. Outcomes included, “achieve appropriate pain score at or below the patient’s pain management goal,” and, “numeric pain score (0-10) expectation 4 or 3 or 2 or 1 or 0.” A review was made of Patient 34’s physician’s order dated 6/25/24 at 2:58 pm, by MD 2 for morphine (a controlled, potent narcotic pain reliever) 4 milligrams (mg) IVP (injected into the vein) given every two hours as needed for pain or air hunger (the sensation of severe breathlessness). A review was made of Patient 34’s pain assessment performed on 6/25/24 4:14 pm, using the FLACC pain scale (a behavioral pain assessment tool to evaluate pain in nonverbal persons, usually children, in which points are assigned for various behaviors and movements as indicators of discomfort); the scoring total assigned was level “5”. A review was made of Patient 34’s medication administration record dated 6/25/24 4:15 pm, when morphine 4 mg IVP was administered by Registered Nurse (RN) A for a FLACC score of “5”, indicating moderate pain. A review was made of Patient 34’s medication administration follow-up entered on 6/25/24 at 5:08 pm, in which RN 6 indicated “yes,” that medication was effective, and symptoms improved, but no pain score was entered indicating how effective the medication was, and therefor there was no clarity that Patient 34’s pain was adequately treated or if more interventions were needed to keep him comfortable. A review was made of Patient 34’s pain assessment performed on 6/25/24 6:15 pm, using the FLACC pain scale for a pain assessment score of “8”, indicating severe pain. A review was made of Patient 34’s medication administration record dated 6/25/24 6:15 pm, when RN 4 administered morphine 4 mg IVP. A review was made of Patient 34’s medication administration follow-up entered on 6/25/24 at 7:13 pm, in which RN 4 indicated “yes,” that medication was effective, but no pain score was entered indicating how effective the medication was. During a concurrent interview, and record review, on 9/25/24 10:25 am, the Director of Nurses (DON) stated, if you have a pain level “8” but it’s improved to only a “7” there is still pain. If that’s outside the patient’s threshold for pain tolerance, then more interventions would still need to be completed which needs a pain intensity score for a basis of comparison.”

“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: 34975 Based on observation, interview, and facility document review, the facility failed to maintain a clean and sanitary environment for the kitchen and the disaster food storage area, and prevent potential cross-contamination (the transmission of infection from a contaminated source to an uncontaminated party) as evidenced by: 1. Lack of maintaining the kitchen free of flies; 2. Lack of maintaining cabinets and shelving free of peeling paint in food preparation and food equipment/utensil storage areas; 3. Lack of maintaining clean cabinets/shelving for food preparation and service equipment; 4. Lack of maintaining clean food storage racks in the walk-in refrigerator; 5. Lack of maintaining the walk-in refrigerator floor smooth and easy to clean; 6. Lack of maintaining the ceiling over the food preparation area, in good condition; 7. Lack of maintaining an outside food grease storage container free of grease and food particles on the outside surface; 8. Lack of maintaining stored disaster food 6 inches off the floor; These failures had the potential to create negative health outcomes for patients, staff, and visitors. Findings: A review, was made of a facility policy and procedure titled, “Infection Prevention Control (IPC) Plan” revised 3/13/24, which described a systemic, coordinated approach to reduce the risks of infection transmission via multiple methods, including the maintenance of a sanitary environment, monitoring areas such as food storage, preparation, refrigerators, and the mitigation of risks associated with patient infections, whether present upon admission or acquired while in the facility. 1. An observation, in the kitchen and concurrent interview, with the Dietary Services Manager (DSM) on 9/23/24 at 12 pm, showed at least three active flies in the food preparation area. In addition, there were multiple active flies, outside close to the back door of the kitchen, and when the door was opened to walk through, a fly entered the kitchen. DSM stated an insect barrier was needed for the back door and there was a plan to add an air curtain to prevent flies from entering the kitchen. During an interview, on 9/24/24 at 8:15 am, Facilities and Engineering Staff (FES) stated, that he was aware of the need for an insect barrier for the kitchen back door. FES stated, that he could install an air curtain (a downward-facing blower fan mounted over an entrance of a building to prevent air, contaminants, or flying insects from moving inside) from on the back door but he was very busy and did not have time, and parts were not ordered yet. A review, of the Environmental Tours Checklist dated July 29, 2024, showed flies were found and consider an air curtain at the back door. During an interview, on 9/26/24 at 9:50 am, the Infection Preventionist (IP) stated, that the presence of flies in the kitchen could have been addressed “sooner,” such as the installation of an air curtain. IP stated when FES was aware of the fly issue, parts could have been ordered for the air curtain. According to the 2022 Federal Food Code, the premises shall be maintained free of insects. The presence of insects shall be controlled to eliminate their presence on the premises. 2. During an observation in the kitchen, and concurrent interview, with DSM on 9/23/24 at 12:10 pm, showed the shelving above a food preparation table, was painted and the paint was peeling. In addition, in the center of the kitchen were drawers and cabinets which held cooking equipment and utensils. The drawers and cabinets were painted and had peeling paint. The surface of the drawers and cabinets, where the paint was peeling, were sticky to the touch. DSM confirmed the paint on the shelving, drawers, and cabinets were peeling and stated the paint was touched up in May, but it was peeling again. During an interview, on 9/23/24 at 3:15 pm, DSM stated, that she did weekly kitchen inspections, and the Registered Dietician (RD) did monthly kitchen inspections and were documented on a sanitation checklist. DSM’s inspection checklists for the month of August and September were requested. Also, RD checklists for the past four months were requested. Review of the “Kitchen Sanitation Checklist” completed and signed by DSM on 8/2/24, 8/8/24, 8/16/24, 8/23/24, 8/29/24, 9/6/24, 9/12/24, and 9/20/24, showed painted surfaces had chips on each of the checklists. During an interview, on 9/24/24 at 8:40 am, FES stated, that he just painted the shelving, cabinets, and drawers in the kitchen about six months ago. FES stated he was aware the paint was currently peeling, and the peeling paint was observed in the last Environment Tour about 1.5 months ago (FES could not recall the exact date). During an interview, and document review, on 9/24/24 at 10:45 am, the RD stated she did an inspection once a month and she documented chipping paint on her monthly sanitation checklist for the kitchen. Four of RD’s most recent “Kitchen Sanitation Checklist” dated 5/21/24, 6/25/24, 7/30/24, and 8/20/24, showed painted surfaces had chips. During an interview, on 9/26/24 at 9:30 am, the Director of Operations (DO; DSM’s Supervisor) stated she did not see the sanitation checklists from DSM, or the RD. During an interview, on 9/26/24 at 9:50 am, IP stated she did not see the sanitation checklists from DSM or the RD. According to the 2022 Federal Food Code, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of corrosion-resistant, nonabsorbent, and smooth material. In addition, equipment must be designed and constructed to be durable and capable of retaining their original characteristics. Equipment must be designed and constructed so that parts do not break and end up in food as foreign objects. 3. An observation in the kitchen, and concurrent interview, with DSM on 9/23/24 at 12:15 pm, showed cabinets in the center of the kitchen holding serving and cooking utensils and equipment. There were patches of dried, yellowish residue on the surface of the shelving. There was also a significant among of brown debris resembling small wood chips on the surface of the shelving. DSM stated the shelving inside the cabinets were dirty. During an interview, with DSM and Kitchen Staff 1 (KS1) on 9/23/24 at 3:18 pm, DSM stated the cabinets were on the cleaning schedule and the cleaning was signed off by KS1 over the weekend on 9/21/24, and 9/22/24. DSM stated the shelving inside the cabinets did not appear they were cleaned over the weekend despite the cleaning being signed off. KS1 stated she used soapy water and sanitizer to clean the surface of the cabinet shelving. KS1 also confirmed, that she signed off the cleaning of the cabinets on 9/21/24, and 9/22/24, but she did not clean the cabinets on 9/21/24, and 9/22/24. KS1 stated it was a busy weekend, so she did not get to it. DSM stated she trained staff to sign off on the cleaning schedule even when tasks were not done so there were no blank and unsigned spaces. Then KS1 stated she did not know the cabinets were not cleaned over the weekend. During an interview, on 9/24/24 at 10:45 am, the RD stated she looked at log documentation in the kitchen when she did her monthly sanitation checklists. RD stated it was fraudulent activity to intentionally document inaccurate information. According to the 2022 Federal Food Code, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, an other debris. In addition, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The 2022 Federal Food Code Annex explains cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. 4. An observation in the kitchen, and concurrent interview, with DSM on 9/23/24 at 12:06 pm, showed food storage racks located inside the walk-in refrigerator with white and brown, rough to the touch, residue build-up on the wire surface of the racks. DSM confirmed there was residue build-up on the racks and stated kitchen staff were responsible for cleaning them. DSM stated the racks were removed and washed down. DSM also stated it was part of a plan of correction from a survey in May, to replace the racks. During an interview, on 9/23/24 at 3:15 pm, DSM stated the food storage racks located in the walk-in refrigerator were cleaned monthly, but were not on the cleaning schedule, so there was no documentation to show when they were last cleaned. DSM stated the racks should be cleaned prior to the monthly cleaning if they became dirty. DSM stated if the racks were dirty before the monthly cleaning, she documented the dirty racks on her weekly inspection checklist. DSM stated the RD and her supervisor (the Director of Operations), received her weekly sanitation checklists. The inspection checklists for the month of August and September were requested. Review of the “Kitchen Sanitation Checklist” completed and signed by DSM on 8/2/24, 8/8/24, 8/16/24, 8/23/24, 8/29/24, 9/6/24, 9/12/24, and 9/20/24. Each of the checklists were marked “no” for the section refrigerator “shelves, racks, walls, floors, ceiling and doors clean.” During an interview, on 9/24/24 at 8:47 am, DSM stated when she documented on the checklist “no” for refrigerator shelves, racks, walls, floors, ceiling, and doors clean, it meant the entire refrigerator was in poor condition including the racks. During and interview, on 9/24/24 at 10:45 am, the RD stated she was aware of residue build-up on the food storage racks located in the walk-in refrigerator, but she did not document the residue build-up recently on her monthly sanitation checklist. During an interview, on 9/25/24 at 1:25 pm, despite the poor condition of the walk-in refrigerator racks, DS confirmed nothing was documented about the walk-in refrigerator on the last Environmental Tour Checklist dated July 29, 2024. During an interview, on 9/25/24 at 2:37 pm, DSM stated during the Environmental Tour it was difficult to discuss all the issues in the kitchen due to so many people on the Environmental Tour team looking at different areas at the same time. She stated she was pulled in different directions and did not get a chance to discuss the condition of the walk-in refrigerator. According to the 2022 Federal Food Code, materials that are used in the construction of food-contact surfaces of equipment shall be durable and corrosion-resistant under normal use conditions and shall have a smooth and cleanable surface. Food contact surfaces shall be clean to sight and touch. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, an other debris. In addition, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of corrosion-resistant, nonabsorbent, and smooth material. 5. An observation in the kitchen, and concurrent interview, with DSM on 9/23/24 at 12:06 pm, showed the floor inside the walk-in refrigerator had residue build-up and debris in a half-inch gap along the floor and the metal threshold/transition strip. During an observation, and interview, on 9/24/24 at 8:40 am, FES confirmed there was a gap in the walk-in refrigerator floor and stated the floor was corroded. FES stated he was aware of the poor condition of floor and the floor needed to be replaced.. Review of the “Kitchen Sanitation Checklist” completed and signed by DSM on 8/2/24, 8/8/24, 8/16/24, 8/23/24, 8/29/24, 9/6/24, 9/12/24, and 9/20/24, showed each of the checklists showed were marked “no” for the section refrigerator “shelves, racks, walls, floors, ceiling and doors clean.” During an interview, on 9/24/24 at 8:47 am, DSM stated when she documented on the checklist “no” for refrigerator shelves, racks, walls, floors, ceiling, and doors clean, it meant the entire refrigerator was in poor condition including the floors. During an interview, on 9/24/24 at 10:45 am, the RD stated she was aware of the poor condition of the walk-in refrigerator floor but did not document about the refrigerator floor on her monthly sanitation checklist. During an interview, on 9/25/24 at 1:25 pm, despite the poor condition of the walk-in refrigerator floor, DS confirmed nothing was documented about the walk-in refrigerator on the last Environment Tours Checklist dated July 29, 2024. During in interview, on 9/25/24 at 2:37 pm, DSM stated during the Environmental Tour it was difficult to discuss all the issues in the kitchen due to so many people on the Environmental Tour team looking at different areas at the same time. She stated she was pulled in different directions and did not get a chance to discuss the condition of the walk-in refrigerator. According to the 2022 Federal Food Code, floor surfaces under conditions of normal use shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted. 6. An observation in the kitchen, and concurrent interview, on 9/24/24 at 8:45 am, showed an open crack in the ceiling above a food preparation table. FES stated he was aware of the crack which he observed during the last Environment tour. During an interview, and document review, on 9/24/24 at 10:45 am, the RD stated she did document the cracked ceiling on her last monthly sanitation checklist. RD’s checklist dated 8/20/24, was marked “no” under the Maintenance section for “All floors, walls, ceiling tiles in place and not cracked”. “Cracked” was circled by RD. During an interview, and document review, on 9:25 at 9:10 am, the of the “Environmental Tours Checklist” dated July 29, 2024, showed “visible leak with the ceiling material bubbling up”. FES confirmed this documentation was for the crack observed in the ceiling. It was noted this project was not assigned to anyone and the plan of correction showed “working with maintenance”. According to the 2022 Federal Food Code, materials for indoor ceiling surfaces under conditions of normal use shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted. 7. An observation, and concurrent interview, with DSM on 9/23/24 at 11:58 am, showed a metal container two feet deep and four feet in length, located outside the backdoor of the kitchen. The top surface of the container appeared greasy and had brown particles resembling fried food crumbs. DSM stated this metal container held used cooking grease from the kitchen. DSM stated the kitchen staff opened the lid to the box and poured the grease into the container. DSM confirmed there was grease and food particles on the top surface and stated maintenance cleaned the area. An observation, and concurrent interview, on 9/24/24 at 8:15 am, showed the metal grease container was still greasy with food crumbs on the top surface. FES stated facilities (maintenance) did not really maintain the area, and stated it was “dietary” responsibility. During an interview, with IP and DS on 9/25/24 at 1:50 pm, IP stated the Environmental Tour did not include going outside behind the kitchen. IP stated food grease and particles could attract “critters.” DS stated the metal grease container was always greasy on the outside surface. According to the 2022 Federal Food Code, soiled receptacles and waste handling units for refuse shall be cleaned at a frequency necessary to prevent them from developing buildup of soil or becoming attractants for insects and rodents. 8. During an observation, and concurrent interview, on 9/26/24 at 11:30 am, disaster food was observed in an outside storage area. The bottom shelf was 2.5 inches off the floor and held food such as cases of dried cereal and cans of food. DSM confirmed the food was stored 2.5 inches off the floor and it should be stored at least 6 inches above the floor. According to the 2022 Federal Food Code, Food shall be protected from contamination by storing the food at least 6 inches above the floor.”