Monroe County Hospital

“42 CFR 485.623(d) Monroe County Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.41 (b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition. Monroe County Hospital is a one-story building that was built in 1965 and 2000. The building is composed of Type II (000) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms and the spaces open to the corridors. The facility has 25 certified beds. At the time of the survey the census was 3. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“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: 49482 Based on observation, interview and record review, the facility failed to provide all cooking equipment with a commercial kitchen ventilation hood for the collection and exhaust of heat, steam and cooking vapors or a commercial cooking suppression system to collect and remove grease-laden vapors and extinguish fire in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 12.1.2. This deficient practice affected the kitchen area. This facility had a capacity of 25 and a census of 3 residents at the time of the survey. Findings include: Observation and record review on 3/23/26, at approximately 12:37 p.m., revealed the hood suppression pull stations tag showed last inspection was February 2025 with a note written that stated, see report. Record review of the facilities hood suppression system inspection paperwork from 3/4/26 had a note stating, “system out of compliance.” Maintenance Staff confirmed the observation at the time of discovery.”

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 49482 Based on record review and interview, the facility failed to maintain complete documentation of sensitivity testing of the smoke detectors every two years in accordance with in accordance with National Fire Prevention Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 edition, 14.4.5.3.2 and 14.6.2.4. The deficient practice of not providing complete and verifiable documentation of the fire alarm system’s inspection, testing and maintenance did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 25 and a census of 3 residents at the time of the survey. Findings include: Record review on 3/23/26, at approximately 1:21 p.m., revealed the facility was unable to produce recent documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacturer. These deficient practices were confirmed by Maintenance Staff at the time of discovery.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 49482 Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6 for four of four quarters reviewed. The documentation did not show the drills have been held as required, including varying conditions (such as timing and the day of the drill). This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility had a capacity of 25 and a census of 3 residents at the time of the survey. Findings include: Record review on 3/23/26, at approximately 11:21 a.m., of the facility fire drill documentation conducted during 2025/2026 revealed the following: 1. Four of the four first shift drills were conducted at 9:30 a.m., 9:32 a.m., 8:59 a.m., and 9:00 a.m. Drills conducted in the first quarter were all conducted on 3/5/26 or 3/6/26. 2. Four of the four second shift drills were conducted at 3:25 p.m., 3:30 p.m., 3:58 p.m., and 4:00 p.m. All drills conducted in the 2nd quarter were conducted on 6/19/25. 3. Four of the four third shift drills were conducted at 6:00 a.m., 5:35 a.m., 5:43 a.m., and 5:00 a.m. All 3rd quarter drills were conducted on 9/19/25. 4. All fourth quarter fire drills were conducted on 12/9/25. Results of the record review were acknowledged by Maintenance Staff and Administrative Staff at the time of exit.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 50440 Based on a review of hospital policies, documents, and interviews with staff, the Critical Access Hospital (CAH)’s administrative staff failed to ensure 7 out of 14 of the selected CAH’s policies and procedures were reviewed biannually. Failure to review policies may lead to noncompliance with local, state, and federal laws that may not reflect current industry and community standards and could result in a lower quality of care and decreased safety for patients presenting to the hospital. Findings include: 1. Review of the policy last approved 08/2025, “Policy Development and Review” revealed in part: “Policy: Policies and procedures shall be compliant with local, state, and federal laws, legal and administrative rules, and reflect current industry and community standards. All policies shall be reviewed at a minimum of every two fiscal years. Procedure: 1. Development/revision may be initiated at the administrative, management, or departmental level. Existing policies/procedures should be reviewed and considered first. All new/revised clinical policies will be approved by the Professional Advisory Committee (PAC) prior to implementation. They will then advance to the Medical Staff for approval, then to the Board of Trustees for final approval. Non-clinical policies will advance directly to the Board of Trustees after approvals in the work flows are complete. 2. Review of the selected policy “Peer Review” revealed the policy “shall maintain effective quality assurance through internal medical staff peer review and external staff peer review provided through an agreement with a network hospital or other qualified external review organization,” was last approved on 09/2023 with the next review of the policy on 09/2025. a. Review of the selected policy “Activities Program” revealed “there will be an activities program available for all skilled and extended care patient[s] to provide stimulation to promote physical and mental well being to maintain or improve the health of each patient,” was last approved on 11/2020 with the next review of the policy on 11/2022. b. Review of the selected policy “Crash Cart Policy” revealed the policy stated “the crash care maintained on the nursing unit will be checked twice daily, once on the 7a shift and once on the 7p shift to validate intactness of integrity seal and related emergency care supplies and equipment. The check list in the crash cart book will be signed. The crash cart will be unlocked and completely checked once per month shift,” was last approved on 04/2021 with the next review of the policy on 04/2023. c. Review of the selected policy “Handling of Records” revealed the policy stated “security and confidentiality of patient records should be maintained at all times. Health Information Management personnel should handle records during business hours. Outside of these hours, only authorized hospital personnel are to take records from the Health Information Management (HIM) Department,” was last approved on 10/2023 with the next review of the policy on 10/2025. d. Review of the selected policy “Patient Confidentiality” revealed “every employee, volunteer, student, member of the Medical Staff and Administration will protect the confidentiality of any private information ... from a patient, or from any source, about a patient,” was last approved on 03/2009 with the next review of the policy on 03/2011. e. Review of the selected policy “Standards of Practice” revealed “the Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. ...Includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation ...” was last approved on 11/2023 with the next review of the policy on 11/2025. f. Review of the selected policy “Swing Bed Transfer/Discharge” revealed “MCHC will provide guidelines for sufficient notice of discharge. ...to ensure that the patient is sufficiently prepared and oriented for a safe and orderly transfer or discharge ...”, was last approved on 09/2022 with the next review of the policy on 09/2024. 3. During an interview on 3/18/26 at 3:30 pm, Laboratory Manager reported they signed off on their policies related to the lab prior to going on vacation the previous week of 3/9/26. The policy reviews were pending for review from 2021 and awaiting signature from administrative staff.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (v) Procedures for reporting adverse drug reactions and errors in the administration of drugs. This Standard is not met as evidenced by: 50440 Based on a review of hospital policies, documents, and interviews with staff, the Critical Access Hospital (CAH)’s administrative staff failed to ensure hospital staff appropriately documented and reported medication errors for 13 of 14 sampled patients. Failure to appropriately document and report medication errors, in accordance with hospital policies and procedures, could result in the administration of incorrect medications, incorrect medication dosage, or incorrect dosing frequency, thereby increasing patients’ risk of experiencing a serious adverse health outcome. Findings include: 1. Review of the policy last approved 06/2025, “Adverse Drug Events” revealed in part: “Policy: ... reporting of adverse drug events (ADE’s), and potential adverse medication events (PADE’s) as a means to assess and improve the medication use process and provide a safe environment for patient care. The purpose of the reporting errors is to learn about the cause of the error and enhance the medication system to make it difficult for practitioners to commit errors. Practitioners involved in medication use are required to participate in the detection and reporting of errors ... Procedure: 1. It is the responsibility of all clinical staff to report ADRs. a. The attending physician or physician on call and appropriate nursing staff should be notified immediately of any suspected ADRs ... The physician/nursing staff will document the ADR in the medical record ...” 2. Review of the Incident Management / Quality Improvement Medication Error form completed on 3/29/25 at 8:13 pm and 3/30/25 revealed Patient #1 (P1) received the incorrect dose of rasagiline (used to treat Parkinson’s disease to improve movement symptoms) at 0.5mg for a half tab that was ordered for 1 tab of 0.5gm at HS (bedtime). There was no indication the provider was notified. a. Review of the Incident Management / Quality Improvement Medication Error form completed on 3/31/2025 at 12:00 pm revealed Patient #2 (P2) had medication order errors for the following medications: celebrex (anti-inflammatory drug used for pain relief) 100mg that the nurse who administered, commented the ordered should have been 400mg; oxycodone (used to treat pain) 5mg that the nurse who administered, commented the order should have been 10mg; fentanyl (used for pain relief) 0.5mcg that the nurse who administered, commented should have been 50mcg. Through investigation by the facility, the order was verbally provided as 50mcg q5min (every 5 minutes) prn (as needed) for a maximum dose of 250mcg. There was no indication the provider was notified. b. Review of the Incident Management / Quality Improvement Medication Error form completed on 4/18/2025 at 9:00 am revealed Patient #3 (P3) received Dtap (a vaccine for diphtheria, tetanus, and acellular pertussis) instead of Tdap (a booster vaccine of reduced diphtheria/pertussis to maintain immunity). There was no indication the provider was notified. c. Review of the Incident Management / Quality Improvement Medication Error form completed on 5/22/2025 at 4:48 pm revealed Patient #4 (P4)’s hydrocodone-APAP (to treat severe pain and fever) 5-325mg tab was dispensed from the Omnicell. At 5:00 pm, hydrocodone-APAP 5-325mg 0.5 tab was wasted without indication the medication was given to the patient. There was no indication the provider was notified. d. Review of the Incident Management / Quality Improvement Medication Error form completed on 6/30/2025 at 8:51 pm revealed Patient #5 (P5) had medication taken from the Omnicell to be administered but the nurse believed it was given in the emergency room (ER). A “Teams” message was sent to a provider but it was not indicated when the message was sent and if the patient was under the care of the provider. e. Review of the Incident Management / Quality Improvement Medication Error form completed on 7/9/2025 at 5:23 pm revealed Patient #6 (P6) received 3 benzocaine (topical anesthetic for reducing pain) 15mg / Menthol 3.6 mg lozenges of Cepacol (brand of pain relief medication lozenge). The order was for benzocaine 6mg / Menthol 10 mg lozenges of Chloraseptic (brand of pain relief medication lozenge). There was no indication the provider was notified. f. Review of the Incident Management / Quality Improvement Medication Error form completed on 9/7/2025 at 7:00 am revealed Patient #7 (P7) received hydrocodone, tramadol (used to treat severe pain), and an enema that was not ordered. The nurse who administered the medications said they did not document anything since there was no order. There was no indication the provider was notified. g. Review of the Incident Management / Quality Improvement Medication Error form completed on 10/31/2025 at 6:28 pm revealed Patient #8 (P8) requested an influenza vaccine prior to discharge. The pharmacy placed the order for the patient’s vaccine into the MAR prior to discharge. Patient #8 did not receive their influenza vaccine before they were discharged. There was no indication the provider was notified. h. Review of the Incident Management / Quality Improvement Medication Error form completed on 11/2/2025 at 8:41 am revealed Patient #9 (P9) received 2 doses of prednisolone (used to treat allergies, inflammation, asthma, arthritis, and certain cancers) 15mg/5ml solution for home use. The provider order was for 1 dose to home. There was no indication the provider was notified. i. Review of the Incident Management / Quality Improvement Medication Error form completed on 12/5/2025 at 11:00 am revealed Patient #10 (P10) requested to receive an influenza vaccine upon discharge. The order was placed for the vaccine to be administered before the patient was discharged. Patient #10 did not receive the influenza prior to discharge. There was no indication the provider was notified. j. Review of the Incident Management / Quality Improvement Medication Error form completed on 12/24/2025 at 2:00 pm revealed Patient #11 (P11) received an ambulatory grenade (portable, disposable device used for continuous and controlled delivery of medication) by Med Surg nursing staff on 12/25/25 and reported the infusion was not working. It was noted the PICC (flexible tube inserted into a peripheral vein for intravenous treatments (IV)) was clamped. There was no indication the provider was notified. k. Review of the Incident Management / Quality Improvement Medication Error form completed on 2/14/2026 at 7:16 am revealed Patient #12 (P12) received hydromorphone (used to treat pain) 0.25gm. The order was for 0.5gm, which did not match the 1mg/ml injection was removed from the Omnicell. It was noted that 0.5mg was wasted. There was no indication the provider was notified. l. Review of the Incident Management / Quality Improvement Medication Error form completed on 3/1/2026 at 10:00 am revealed Patient #13 (P13) received their thyroid medication at 6:00 am and again at 10:00 am. The medication was scheduled to be administered at 10:00 am but the overnight nurse gave the medication at 6:00 am. There was no indication the provider was notified. 3. During an interview on 3/19/26 at 10:45 am, The Med Surg Nurse Manager confirmed the patient charts selected were not compliant with the requirements for notifying the physician.”

“PROTECTION OF RECORD INFORMATION CFR(s): The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use. This Standard is not met as evidenced by: 50440 Based on a review of hospital policies, documents, observations, and interviews with staff, the Critical Access Hospital (CAH)’s administrative staff failed to ensure hospital staff maintained safeguards to protect patient medical records information and secure them from unauthorized access by placing paper copies of patient medical record information upside down in a tray located on a shelf several feet away from the main nurse’s desk. The shelf is next to a wall that staff and visitors in the Med Surg inpatient unit frequently walk by or stand near when engaged with other nursing staff within the nursing station. Failure to secure patient medical information could compromise personal patient information, decrease trust of medical staff and the healthcare systems, and lead to damaged or stolen patient information that may be critical for patient treatment and care within the facility. Findings include: 1. Review of the policy last approved, 3/2009, “Patient Confidentiality” revealed in part “policy: every employee,... member of the Medical Staff and Administration will protect the confidentiality of any private information which may be acquired from a patient, or from any source, about a patient. Procedure: 1. It is the obligation of each employee,... member of the Medical Staff and Administration to protect the confidentiality of any private information which may be acquired from a patient, or from any source, about a patient.” 2. During a tour on 3/18/26 at 2:45 pm on the Med Surg inpatient unit, observations revealed the Unit Clerk placed patient medical records forms faced down into a metal open rack located on a shelf next to the wall on the unit. The patient medical records forms were at shoulder level and could be easily grabbed by staff members walking inside or outside of the nursing unit desk. 3. During an interview on 3/18/26 at 4:20 pm, the Unit Clerk reported, when a patient is discharged, their paper medical record information is collected, paperclipped, and then placed face down on a tray at the edge of the nurses’ station (by an entryway wall away from the unit clerk’s seating area and desk). The patient medical record forms are to be picked up one to two times per day by HIM staff. The Unit Clerk confirmed patient medical record information is placed on the tray after hours, despite HIM staff pick up times concluding, and over the weekend, where they would remain until the following Monday to be picked up.”