Yuma District Hospital

“INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility’s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 482.41(b). The facility is one story, Type II (222), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 2007 and is license for 15 beds. The 15 bed hospital is separated from the adjacent clinic (business) occupancy by two-hour fire rated construction. This re-certification survey conducted on November 19, 2025 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19, “Existing Health Care Occupancies”. The deficiencies cited were discussed with the Hospital CEO, Physical Plant Manager and Maintenance staff during the exit conference conducted at the end on-site survey.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 47557 Based on observation and interview with facility personnel, the kitchen area was not maintained in accordance with NFPA 101 and NFPA 96. Findings include: 1. Kitchen appliances on casters were not equipped to be returned to their original location after moving. 2. There was no Kitchen hood cleaning documentation available at the time of the survey Regulatory Reference: NFPA 96 13.1.2.3 The fire-extinguishing system shall not require re-evaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations, and any disconnected fire-extinguishing system nozzles attached to the appliances are reconnected in accordance with the manufacturer ’ s listed design manual. 13.1.2.3.1* An approved method shall be provided that will ensure that the appliance is returned to an approved design location. NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. 11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. 11.4 Table Systems serving moderate-volume cooking operations Semiannually Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 47557 Based on record review and interview, it was found that the facility documentation was not compliant with NFPA 101 and NFPA 72. Findings include: During documentation review, with facility staff, it was found that the facility’s fire alarm records did not indicate that a semi-annual visual inspection was completed for the facility ’ s smoke detectors. Regulatory Reference: NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72 14.3 Inspection. 14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“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: 47557 Based on observation, documentation review, and interview with facility personnel, the facility failed to maintain its Fire Sprinkler System in accordance with NFPA 101, NFPA 13, and NFPA 25. Findings include: 1. There was no semi-annual sprinkler report available for review during the survey 2. 5-year internal inspection: No inspection report available for review. Facility confirmed that the 5-year was overdue and being scheduled. 3. Sprinkler gauges were more than 5 years old 4. Freezer sprinkler head listed as more than 10 years old on the inspection report 5. No Inventory listing for spare sprinkler heads Regulatory Reference: NFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 25 5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat-responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“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: 47557 Based on observations and interviews with facility personnel, facility fire extinguishers were not maintained in accordance with NFPA 101 and NFPA 10 Findings include: 1. Extinguisher not signed off in OR 1 2. Extinguisher missed for annual inspection OR exit NFPA 10 7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 7.3* Maintenance. 7.3.1 Frequency. 7.3.1.1 All Fire Extinguishers. 7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 47557 Based on observations and interviews with facility personnel, facility fire and smoke barriers were not maintained in compliance with NFPA 101. Findings include: Penetrations: 3 of 4 Smoke compartments (Multiple penetrations 10 plus penetrations found) - Surgical Department door above the ceiling (at doors and around the corner) - Staff Lounge Wall, Business corridor - Sleep study corner (1 hr wall/and smoke partition) Regulatory Reference: NFPA 101 19.3.6.2 Construction of Corridor Walls. 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8. 19.3.6.2.2* Corridor walls shall have a minimum 1/2-hour fire resistance rating. 19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke. 8.3.1.2* Fire barriers shall comply with one of the following: (1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. (2)The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. 8.3.2 Walls. 8.3.2.1 The fire-resistive materials, assemblies, and systems used shall be limited to those permitted in this Code and this chapter. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“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: 47557 Based on observations and interviews with facility personnel, the condition of the facility’s fire doors could not be verified through inspection documentation in accordance with NFPA 101 and NFPA 80. Findings include: Annual Fire Door Inspection: No inspection report available for review during survey (Including Bistro drop-down door) Regulatory Reference: NFPA 80 5.2* Inspections. 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly. 5.2.4.2 As a minimum, the following items shall be verified: (1)No open holes or breaks exist in surfaces of either the door or frame. (2)Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3)The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4)No parts are missing or broken. (5)Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6)The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (7)If a coordinator is installed, the inactive leaf closes before the active leaf. (8)Latching hardware operates and secures the door when it is in the closed position. (9)Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10)No field modifications to the door assembly have been performed that void the label. (11)Gasketing and edge seals, where required, are inspected to verify their presence and integrity. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“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: 47557 Based on observations and interviews with facility personnel, the condition of the facility’s fire dampers could not be verified through inspection documentation in accordance with NFPA 101 and NFPA 105. Findings include: 1. Fire Damper Inspection: No inspection report available for review during survey Regulatory Reference: NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 47557 Based on observation and interview, the facility failed to have a compliant emergency plan in accordance with NFPA 101. Findings include: During the record review, it was discovered that the facility’s emergency plan did not meet all the requirements of NFPA 101. The Facility Director of Quality & Regulatory Compliance mentioned that the facility is working to update its emergency plans for compliance. Regulatory Reference: NFPA 101 19.7.2.1* Protection of Patients. 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. 19.7.2.1.2 The basic response required of staff shall include the following: (1)Removal of all occupants directly involved with the fire emergency (2)Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff (3)Confinement of the effects of the fire by closing doors to isolate the fire area (4)Relocation of patients as detailed in the health care occupancy ’ s fire safety plan 19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following: (1)Use of alarms (2)Transmission of alarms to fire department (3)Emergency phone call to fire department (4)Response to alarms (5)Isolation of fire (6)Evacuation of immediate area (7)Evacuation of smoke compartment (8)Preparation of floors and building for evacuation (9)Extinguishment of fire 19.7.2.3 Staff Response. 19.7.2.3.1 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. 19.7.2.3.2 All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions: (1)When the individual who discovers a fire must immediately go to the aid of an endangered person (2)During a malfunction of the building fire alarm system 19.7.2.3.3 Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 47557 Based on observations and interviews with facility personnel, patient area curtains did not display evidence of fire rating and could not be verified during survey. Findings include: Curtains throughout the facility ’ s patient areas do not display a fire rating requirement iaw NFPA 101. Regulatory Reference: 10.3 Contents and Furnishings. 19.7.5.1* Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1(see 19.3.5.11), and the following also shall apply: (1)Such curtains shall include cubicle curtains. (2)Such curtains shall not include curtains at showers and baths. (3)Such draperies and curtains shall not include draperies and curtains at windows in patient sleeping rooms in smoke compartments sprinklered in accordance with 19.3.5. (4)Such draperies and curtains shall not include draperies and curtains in other rooms or areas where the draperies and curtains comply with all of the following: (a)Individual drapery or curtain panel area does not exceed 48 ft2 (4.5 m2). (b)Total area of drapery and curtain panels per room or area does not exceed 20 percent of the aggregate area of the wall on which they are located. (c)Smoke compartment in which draperies or curtains are located is sprinklered in accordance with 19.3.5. 10.3.1* Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall meet the flame propagation performance criteria contained in NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“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: 47557 Based on observations and interviews with facility personnel, the facility’s polarity retention testing was not conducted in accordance with NFPA 101 and NFPA 99. Findings include: Polarity Retention Report: Facility performing polarity testing. However, no retention testing is being completed and documented. Regulatory Reference: NFPA Standard: NFPA 99 Health Care Facilities Code (2012) 6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 47557 Based on observations and interviews with facility personnel, the medical gas system could not be verified through inspection documentation in accordance with NFPA 101 and NFPA 110. Findings include: No annual load bank inspection, 3-year 4-hour load bank, or annual fuel inspection report available for review during survey Monthly inspection documentation was not in compliance with NFPA 110. Regulatory Reference: NFPA 110: 8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendations Instruction manuals Minimum requirements of this chapter The authority having jurisdiction 8.3.7 A fuel quality test shall be performed at least annually using applicable ASTM standards or the manufacturer ’ s recommendations. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“Gas Equipment - Testing and Maintenance Requi CFR(s): NFPA 101 Gas Equipment - Testing and Maintenance Requirements Anesthesia apparatus are tested at the final path to patient after any adjustment, modification or repair. Before the apparatus is returned to service, each connection is checked to verify proper gas and an oxygen analyzer is used to verify oxygen concentration. Defective equipment is immediately removed from service. Areas designated for servicing of oxygen equipment are clean and free of oil, grease, or other flammables. Manufacturer service manuals are used to maintain equipment and a scheduled maintenance program is followed. 11.4.1.3, 11.5.1.3, 11.6.2.5, 11.6.2.6 (NFPA 99) This Standard is not met as evidenced by: 47557 Based on observations and interviews with facility personnel, the medical gas system could not be verified through inspection documentation in accordance with NFPA 101 and NFPA 99. Findings include: Med Gas: No inspection report available for review during survey Regulatory Reference: NFPA 99: 5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following: They shall be inspected annually. They shall be maintained by a qualified representative of the equipment owner. A record of the annual inspection shall be available for review by the authority having jurisdiction. Deficient practice was discussed with the hospital leadership team during the survey exit conference.”

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 47557 Based on the life safety code survey completed on 11/19/2025, the facility failed to maintain the building, as constructed, in accordance with NFPA 101, affecting three of four smoke compartments and all patients, personnel, and others within those compartments in the event of a fire. Findings include: Cross reference to T1TJ21 K-0362 - Corridors - Construction of Walls for observations and interviews identifying multiple penetrations in rated walls throughout the building.”

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 44751 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.635 Provision of Services, was out of compliance. C-1024 (b) Standard: Patient Services (1) General. i) The CAH provides those diagnostic and therapeutic services and supplies that are commonly furnished in a physician’s office or at another entry point into the health care delivery system, such as a low intensity hospital outpatient department or emergency department. These CAH services include medical history, physical examination, specimen collection, assessment of health status, and treatment for a variety of medical conditions. Based on interviews and document review, the facility failed to ensure infusion therapy practices, policies, or protocols were established in accordance with nationally recognized guidelines for outpatient infusions performed by patient care unit (PCU) nurses. This failure was identified in two of two outpatient PCU infusion patients reviewed. (Patient #22 and #25)”

“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: 44751 Based on interviews and document review, the facility failed to ensure infusion therapy practices, policies, or protocols were established in accordance with nationally recognized guidelines for outpatient infusions performed by patient care unit (PCU) nurses. This failure was identified in two of two outpatient PCU infusion patients reviewed. (Patient #22 and #25) Findings include: Facility policies: The Lippincott Procedures Use policy read, the facility uses Lippincott Procedures as the official evidence-based clinical procedures manual. The Drug, Biological, and Intravenous Medication Guidelines policy, read all drugs, biologicals, and intravenous medications must be administered in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. Drugs and biologicals must be prepared and administered in accordance with accepted standards of practice and the manufacturer’s recommendations. References: The Lippincott Procedures: Implanted Port Accessing, flushing, and locking procedure read, according to the Infusion Nurses Society (INS), assess the site of the implanted port for infection, thrombosis, device rotation, or skin erosion. An implanted port is accessed with a non-coring needle, flushed with preservative-free normal saline, and locked with either saline or heparin (a medication used to prevent blood clots). The implanted port should be flushed before infusions are initiated to assess the functionality of the implanted port, and after infusions have been administered to prevent medication incompatibility and clotting within the internal catheter. While maintaining sterility, attach a prefilled 10mL syringe (or low-pressure syringe) with saline and flush using at least twice the internal catheter volume. Documentation includes date and time of needle insertion, assessment findings, needle gauge and length, number of attempts, blood return, infusion details (type, amount, rate, method if initiated), flush solution type and volume, flushing resistance, and patient tolerance. According to the INS 2024 Infusion Therapy Standards of Practice, infusion therapy practices should be established within organizational policies, procedures, practice guidelines, and/or standardized written protocols/orders. These practices should include documentation of the type of infusion therapy, the flush solution type and volume, flushing resistance, and the locking of the venous access device (VAD), the medication administered, the medication dosage, the infusion rate, time/duration of the infusion, the administration route (peripheral intravenous access-PIV, implanted port, peripherally inserted central catheter (PICC), long-term intravenous access-midline), the method of infusion (push, continuous, intermittent), the medication administration parameters or special instructions, and the patient’s vital signs prior to and after the infusion therapy. 1. The facility failed to establish outpatient infusion therapy policies, processes, and protocols for prescribing and administering outpatient infusions performed on the PCU in accordance with nationally recognized guidelines A. Document Review i. The physician’s orders sheets for Patient #22 were reviewed and revealed “Lasix (a medication used to lower blood pressure and remove excess fluid) 60 mg intravenous (IV) every Monday, Wednesday, and Friday” was handwritten as an outpatient infusion order on a physician’s orders sheet and dated 8/20/24 at 6:24 a.m. Further medical record review revealed on 9/12/25, Patient #22 had an outpatient infusion performed on the PCU. According to Patient #22’s medical record, at 6:45 p.m., registered nurse (RN) #1 accessed the implanted port located on the right side of Patient #22’s chest and administered 60 mg of Lasix IV push, and at 6:48 p.m., RN #1 flushed the implanted port with 500 units/5 mL of heparin. Upon further review, the infusion order did not instruct the patient’s implanted port could be accessed to infuse the Lasix. Additionally, the infusion order did not specify whether the Lasix infusion should be administered as a push or infusion, and the order did not include the flush type and volume, or blood pressure parameters for safe administration of Lasix. This contrasted with Lippincott Procedures: Implanted Port Accessing, which stated that implanted ports should be flushed before and after infusions to assess the port’s functionality and prevent complications. Furthermore, needle insertion details, port assessments, infusion volumes and duration specifics, flush solution type and volume, flushing resistance, and patient tolerance to the infusion should be documented. ii. A Midline/PICC Insertion procedure report was reviewed for Patient #25. The report revealed on 9/3/25, a midline catheter (venous access device for prolonged IV therapy of antibiotics and fluids) was inserted into Patient #25’s upper left arm. Review of the physician’s order sheets revealed a handwritten outpatient infusion order dated 9/3/25 at 2:08 p.m. for “Ertapenem (antibiotic) 1 g every 24 hours for 14 days IV.” The infusion order did not indicate the midline could be used, gave no instructions on whether Ertapenem should be administered as a push or infusion, and did not specify the type or amount of flush solution to be used before and after the infusion. Additionally, the order lacked instructions on monitoring vital signs or other requirements for safe administration. Further medical record review revealed on 9/4/25, 9/6/25, 9/7/25, 9/9/25, 9/10/25, 9/11/25, 9/15/25, and 9/16/25, there was no evidence the midline in the patient’s upper left arm was flushed or assessed before and after it was accessed for the Ertapenem administration. Upon request, the facility was unable to provide evidence it had established policies, processes, or protocols based on national standards of care for the administration of outpatient infusions by PCU nurses. According to the INS 2024 Infusion Therapy Standards of Practice, infusion orders were to include medication and dose, route of administration, flush type and volume, infusion rate and duration, whether a diluent was used, the final volume, method of administration, and monitoring requirements such as vital signs and labs. These elements were missing from the physician’s orders for both Patient #22 and Patient #25. Furthermore, the outpatient infusions performed by PCU nurses for Patient #22 and Patient #25 contrasted with the INS 2024 Infusion Therapy Standards of Practice which stated infusion documentation in the patient medical records should include how the infusion was administered, such as by push, continuous drip, or continuously infused, the type and volume of the flush solution, whether there was resistance during flushing, the type of locking solution, the medication and dosage, the infusion rate and duration, the route of administration such as IV line, implanted port, PICC line or midline, special instructions, and patient vital signs before and after infusion therapy. B. Interviews i. On 9/18/25 at 10:52 a.m., an interview was conducted with RN #2. RN #2 stated outpatient infusion orders included whether the patient’s implanted port, PICC line, or midline could be accessed for the infusion. RN #2 stated infusion orders specified the type and amount of flush needed for the access device and whether the medication was to be injected, continuously infused, or given as a push. RN #2 stated when infusion orders lacked this information, mistakes could occur and patients could be harmed. This contrasted with the outpatient infusion orders for Patients #22 and #25, which did not include whether the infusion should be administered through an IV line, implanted port, PICC, or midline. Additionally, the infusion orders did not specify the type and volume of the flush solution or the type of locking solution to be used. RN #2 further stated venous access devices were assessed before infusions began and after they ended, and the findings were documented in the medical record. RN #2 stated these assessments ensured the access device functioned, was patent, and had no signs of infection or compromised skin integrity. RN #2 stated when access devices were blocked, dislodged, or had compromised skin integrity, patients were at risk for infections, tissue damage, and pain. This was in contrast to Patient #22’s medical record review, which revealed no evidence the patient’s implanted port was assessed before or after their outpatient infusion on 9/12/25. This also contrasted with the medical record review for Patient #25, which revealed no evidence the midline in the patient’s upper left arm was flushed or assessed before or after their outpatient infusions on 9/4/25, 9/6/25, 9/7/25, 9/9/25, 9/10/25, 9/11/25, 9/15/25, and 9/16/25. ii. On 9/17/25 at 3:24 p.m., an interview was conducted with director of nursing (DON) #3. DON #3 stated nurses were expected to review the infusion orders before infusions were administered. DON #3 stated PCU outpatient infusion orders did not specify if the infusion could be administered using the patient’s implanted port, a PICC line, or a midline. DON #3 further stated infusion orders did not have the flush type and volume, or if the medication should be injected, continuously infused, or administered as a push. Lastly, DON #3 stated the facility did not have outpatient infusion policies or procedures. The interview with DON #3 contrasted with the Drug, Biological, and Intravenous Medication Guidelines policy, which stated intravenous medications were administered in accordance with written and signed orders and accepted standards of practice. The interview also contrasted with the INS 2024 Infusion Therapy Standards of Practice, which stated the facility was to establish infusion therapy practices, policies, procedures, and protocols for infusion therapy documentation and infusion therapy orders.”