Optim Medical Center - Screven

“ANESTHETIC RISK AND EVALUATION CFR(s): (1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed. (2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia. (3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in paragraph (c) of this section. This Standard is not met as evidenced by: 47717 Based on a review of medical records, policies and procedures and staff interviews, it was determined the facility failed to evaluate two (P) (P4 and P7) of 10 patients reviewed for proper anesthesia recovery. Findings included: A review of records revealed that P4 and P7 were not evaluated before discharge for proper anesthesia recovery. A review of the facility’s policy titled “Anesthesia Services”, PolicyStat ID 18015101, last revised 06/2024, revealed the contracted anesthesia provider is responsible for the following: Postoperatively: C. Evaluate the patient’s condition on admission and discharge from the PACU D. Conduct a post-anesthesia interview to include the following: f. Post-anesthesia note. A statement describing the presence or absence of anesthesia complications. g. Complete the standard anesthesia record. h. Sign and date i. Patient discharge assessment j. Remain in the surgery until all patients under the care of the anesthesia provider have been discharged. An interview was conducted with Infection Control Practitioner (ICP) SS in the conference room on 03/04/2026 at 11:15 p.m. ICP SS stated that (Registered Nurse) RN UU routinely reviews anesthesia records after the procedures and informs anesthesia staff regarding missing documentation. ICP SS stated that Chief Nursing Officer (CNO) VV had conversation with the owner of the contracted anesthesia group regarding missing documentation in the recent past. An interview was conducted with Registered Nurse (RN) UU in the Operating Room (OR) Post Anesthesia Care Unit (PACU) on 03/04/2026 at 4:10 p.m. RN UU stated anesthesia has been advised numerous times in the recent past to complete all their paperwork including signature, date and times. RN UU stated when she informs anesthesia providers of this reminder there is no verbal response from them.”

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 47717 Based on a review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that patients were informed of their patient rights for 37 of 40 patients (P) reviewed. Findings included: Ten (P1, P2, P3, P4, P5, P6, P7, P8, P9 and P10) of ten surgical patient records reviewed failed to include documentation that the patient was provided their patient rights. 17 (P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P15, P17, P18, P19, and P20) of 20 inpatient patient records failed to include documentation that the patient was provided their patient rights. Ten (P1, P2, P3, P4, P5, P6, P7, P8, P9, and P10) of ten Emergency Department (ED) patient records failed to include documentation that the patient was provided their patient rights. A review of the facility’s policy titled “Patient Rights and Responsibilities, Registration”, PolicyStat ID 18017213, last revised 01/2024, revealed these rights and responsibilities shall be explained and given to the patient or the patient’s representative (as allowed under state law) before providing or discontinuing care. An interview was conducted with ICP SS in the conference room on 03/04/2026 at 10:00 a.m. ICP SS stated the patient rights and responsibilities is in some of the admission packets but not in others and she does not know why. ICP SS stated the patient right and responsibilities use to be given to all patients at registration and the patient would sign acknowledging they received the information. ICP SS further stated the Ombudsman was included on the patient right and responsibilities form.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 51219 Based on observation and staff interviews it was determined the facility failed to ensure hazard room has door closer. This affects 1 of 5 smoke compartments During a tour of the facility with Staff M on March 3, 2026, between 08:45 AM and 10:30 AM observation revealed that the IT room with storage is missing door closer. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Section 19.3.2.1.3”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 51219 Based on observation and staff interviews it was determined the facility failed to ensure proper material is used for penetrations. This affects 1 of 5 smoke compartments During a tour of the facility with Staff M on March 3, 2026, between 08:45 AM and 10:30 AM observation revealed that in the electrical room there is improper material used to seal penetration. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, Chapter 4, Section 4.6.12.1”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 51219 Based on observation and staff interviews it was determined the facility failed to ensure electrical panel has no open slots. This affects 1 of 5 smoke compartments During a tour of the facility with Staff M on March 3, 2026, between 08:45 AM and 10:30 AM observation revealed that in the basement elctrical panel, there is an open slot. These findings were confirmed by Staff M at the time of discovery. Reference: 2012 NFPA 101, Chapter 19, Sectin 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70, Article 408.7”