Montgomery County Memorial Hospital

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 53650 Based on medical record review, policy review, and staff interviews, the Critical Access Hospital (CAH)’s administrative staff failed to ensure hospital staff administered medications in accordance with written orders and accepted standards of practice, failed to perform necessary clinical assessments prior to drug administration, and failed to appropriately identify, track, and report medication administration errors for 1 out of 10 sampled patients (Patient #4). This failure resulted in Patient #4 (P4) receiving a second dose of a cardiac medication approximately 7 hours earlier than scheduled, without reassessment of the patient’s vital signs prior to the administration of the medication, which may have contributed to a critical drop in the patient’s blood pressure, a severe decline in the patient’s condition, and the patient’s subsequent death. Furthermore, hospital staff failed to appropriately identify and report the event as a deviation from the provider’s written orders. The cumulative effect of these failures and deficient practices resulted in the inability of the CAH’s administrative staff to ensure hospital staff provided necessary and appropriate medical care to all patients, in accordance with hospital policies, procedures, and accepted standards of practice.”

“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: 53650 Based on medical record review, policy review, and staff interviews, the Critical Access Hospital (CAH)’s administrative staff failed to ensure nursing staff identified and reported medication administration errors in a timely and appropriate manner for 1 of 10 sampled patients (Patient #4). Failure to appropriately identify and report medication errors could place patients at an increased risk of having medications administered not in accordance with provider orders or accepted standards of practice. This failure resulted in Patient #4 (P4) receiving two doses of metoprolol (a beta-blocker used to treat high blood pressure and high heart rates) less than 5 hours apart, despite the provider’s order specifying administration once every 12 hours. This medication error could have precipitated a drop in the patient’s blood pressure and could have contributed to the patient’s decline in health and subsequent death. Findings include: 1. Review of the 03/2026 policy “Medication Misadministration” revealed in part: (a). “Policy: Medication misadministration is defined as a dose of medication or parenteral solution that deviates from the order as written on the patient’s chart ...” (b). “Procedure: Fill out event report on all medication misadministrations ...” 2. Review of the 03/2025 policy “Scheduled Medication Administration Times Guide” revealed in part: (a). “Recommended Administration Times for Commonly Prescribed Medication at [the CAH].” (b). “BID: 0900 [9:00 AM] and 2100 [9:00 PM].” 3. Review of Patient #4’s (P4) medical record from 3/7/26 through 3/11/26 revealed that Staff D (ARNP) placed an order for P4 to receive 12.5 mg of metoprolol “BID” on 3/7/26 at 11:45 AM. On 3/10/26 at 8:59 PM, a medication administration error occurred when Staff I (LPN) administered a second dose of metoprolol less than 5 hours after a previous dose of metoprolol had been administered, and 7 hours earlier than scheduled. 4. During an interview on 5/13/26 at 12:30 PM, Staff D (ARNP) reported that medications ordered “BID” should be administered once every 12 hours. Staff D acknowledged that the dose of metoprolol administered on 3/10/26 at 8:59 PM was not administered in accordance with their written order for this medication from 3/7/26. Staff D reported that this medication error could have contributed to P4’s unexpected decline on 3/11/26. Staff D also acknowledged that a Medication Error Report was not appropriately completed for this event. 5. During an interview on 5/12/26 at 2:45 PM, Staff B (Nurse Supervisor) reported, if a staff member attempted to chart a medication administration more than 60 minutes prior to the scheduled time, a pop-up window would appear on the screen to indicate that the medication was not yet scheduled to be administered. Staff B reported the pop-up window must be acknowledged prior to completing the documentation of the medication administration, and a reason must be selected from a drop-down list of options to explain why the medication was administered prior to the scheduled time. 6. Upon review of the CAH’s electronic medical record system, a pop-up window displayed after scanning a medication that was not yet due for administration. The actual scheduled date and time were displayed in the pop-up window, as well as the date and time the medication was scanned. The user was then prompted to “Specify a reason why the medication is being documented early” by selecting an option from a drop-down list. The listed options in the drop-down list included the following: 1. Back-charting an earlier dose, 2. First dose given, 3. Given before procedure/surgery, 4. Given within scheduled time frame, 5. Given with meals, 6. Held for procedure, 7. Medication not available, 8. Nausea/ vomiting, 9. No IV Access, 10. Not Late; previous dose wasn’t charted, 11. NPO, 12. Off nursing division, 13. Patient Request, 14. Physician consultation required, 15. Refused medication, and 16. Other.” 7. During an interview on 5/13/26 at 9:15 AM, Staff I (LPN) reported administering a dose of metoprolol to P4 on 3/10/26 at 8:59 PM, and reported that P4 had also received the same dose of metoprolol less than 5 hours earlier. Staff I reported the charting system flagged the administration of the dose and indicated they had selected “Patient Request” from the drop-down list to explain why the metoprolol was being administered early. Staff I reported being unsure why they had selected “Patient Request” as the reason for administering the dose 7 hours early. Staff I acknowledged the administration of this dose was not administered in accordance with the provider’s written order or accepted standards of practice. Staff I acknowledged that a Medication Error Report was not filed regarding the event, as required. 8. During an interview on 5/12/26 at 3:30 PM, Staff E (Director of Pharmacy) reported that the peak therapeutic effect of metoprolol would occur in a patient 3-4 hours after the medication is administered. Staff E reported P4’s condition began to suddenly decline in the morning of 3/11/26 at around the time that the metoprolol would have reached peak effect in P4’s body. Staff E confirmed that P4 received their evening dose of metoprolol at 8:59 PM on 3/10/26 and that P4 first became symptomatic at 12:25 AM on 3/11/26, approximately 3.5 hours after receiving the metoprolol. Staff E reported that expected symptoms of a metoprolol overdose would be low blood pressure and low heart rate. Staff E acknowledged that P4 began to experience a very low blood pressure and a reduced heart rate 3-4 hours after receiving metoprolol at 8:59 PM on 3/10/26. Staff E reported that it is possible that the metoprolol dose administered on 3/10/26 at 8:59 PM may have contributed to P4’s unexpected decline on 3/11/26. Staff I also confirmed that no Medication Error Report was filed regarding this event. 9. Review of the CAH’s documentation related to a grievance filed on behalf of P4 on 3/23/26, which alleged a possible medication error occurred on 3/10/26 and may have contributed to P4’s premature death, revealed Staff F (Medical Director) reviewed P4’s medical record from 3/10/26 for a potential medication error on 3/26/26. On 3/26/26 at 8:50 AM, Staff F documented that the administration of metoprolol on 3/10/26 at 8:59 PM was not an error and that the medication was administered appropriately. Staff F cited that the administration was appropriate since P4’s vitals were within parameters at the time of administration. Staff F further documented that they would not consider this incident a medication error and acknowledged that no Medication Error Report was filed regarding this event. 10. During an interview on 5/13/26 at 1:15 PM, Staff F (Medical Director) reported reviewing P4’s medical record (chart) on 3/26/26 in response to a grievance filed on behalf of P4. Staff F reported that, after their review of P4’s chart, they concluded the metoprolol was administered appropriately, as the most recent set of vitals prior to the administration were within parameters to receive that dose. Staff F acknowledged that, when they reviewed the medical record on 3/26/26, they did not realize the most recent set of vitals was taken approximately 1.5 hours prior to the administration of that dose. Staff F reported that, when reviewing medical records for potential medication misadministrations, they do not typically cross-reference the time the medication was administered to when the most recent set of vital signs was taken. Staff F stated that it would not be possible to determine whether or not P4’s vitals were within parameters to receive a dose of metoprolol at 8:59 PM on 3/10/26 due to there not being a recent set of vital signs. Staff F also reported that BID Medications are ordered to be administered once every 12 hours. Staff F reported that two doses of metoprolol were administered to P4 within 5 hours on 3/10/26, which they acknowledged was not in accordance with the written and signed order for that medication. Staff F further acknowledged that P4’s unexpected drop in blood pressure was within the expected timeframe that metoprolol would have reached peak therapeutic effect on P4’s blood pressure. Staff F stated that P4 may have overdosed on metoprolol in the evening of 3/10/26, which may have contributed to P4’s unexpected decline in health. 11. During an interview on 5/13/26 at 2:00 PM, Staff Q (Nurse Manager) reported that medications ordered BID were expected to be administered once every 12 hours. Staff Q acknowledged that P4’s administration of metoprolol on 3/10/26 at 8:59 PM was not administered according to accepted standards of practice. 12. During an interview on 5/14/26 at 9:45 AM, Staff S (Chief Nursing Officer) acknowledged that P4’s metoprolol administration on 3/10/26 at 8:59 PM should have been classified as a medication error. Staff S acknowledged that the administration of metoprolol on 3/10/26 at 8:59 PM deviated from accepted standards of practice and was not administered in accordance with the provider’s written order. Staff S acknowledged that no Medication Error Report was filed regarding this event. 13. During an interview on 5/13/26 at 10:15 AM, Staff H (RN) reported caring for P4 on 3/10/26 and on 3/11/26. Staff H reported believing that BID medications did not need to be administered once every 12 hours. Staff H indicated that the only expectation of nursing staff for BID medications is that the medication is just administered twice in one day, regardless of the time between the doses. Staff H reported believing that the administration of metoprolol on 3/10/26 was not a medication error due to the medication only being administered twice in a 24-hour period. Staff H denied awareness that BID medications were expected to only be administered once in a 12-hour period. Review of hospital policies, medical records, and staff interviews revealed nursing staff failed to appropriately identify and report a medication error, wherein staff administered a dose of metoprolol outside of the appropriate timeframe, as indicated by the provider’s orders and accepted standards of practice.”

“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: 53650 Based on medical record review, policy review, and staff interviews, the Critical Access Hospital (CAH)’s administrative staff failed to ensure nursing staff administered medications in accordance with provider orders and accepted standards of practice for 1 of 10 sampled patients (Patient #4). Failure to ensure nursing staff administered medications in accordance with written orders and accepted standards of practice resulted in Patient #4 (P4) receiving a second dose of metoprolol nearly 7 hours ahead of the scheduled time. Furthermore, nursing staff failed to perform a vital sign assessment prior to administering this medication, instead relying on a blood pressure measurement obtained nearly 1.5 hours prior to administration. These failures could have contributed to a decline in the patient’s health and could have placed all patients at an increased risk of serious adverse health outcomes. Findings include: 1. Review of the 03/2026 policy “Medication Administration” revealed in part: (a). “Policy: Medications will be administered in a safe, timely, and efficient manner following the six rights: right patient, right drug, right dose, right route, right time, and right documentation.” (b). “Medication administration is the result of an order from a provider ... The order includes ... frequency. Any illegible or confusing orders must be clarified with the ordering provider before administering the medication.” (c). “Procedure: Medications shall be given no more than 60 minutes before or after the assigned time ...” (d). “The nurse must know the action, side effects, normal dosage range, and nursing implications of the medication to be administered and question the provider if it does not meet these requirements.” (e). “Check each medication against the EMAR [electronic medication administration record] for the right patient ... and right time. The five rights will be checked a minimum of two times before giving the medication.” 2. Review of the 03/2026 policy “Medication Misadministration” revealed in part: (a). “Policy: Medication misadministration is defined as a dose of medication or parenteral solution that deviates from the order as written on the patient’s chart ...” 3. “Review of the 03/2025 policy “Scheduled Medication Administration Times Guide” revealed in part: (a). “Recommended Administration Times for Commonly Prescribed Medication at [the CAH] ...” (b). “BID: 0900 [9:00 AM] and 2100 [9:00 PM] ...” 4. Review of Patient #4 (P4)’s medical record from 3/7/26 through 3/11/26 revealed the following: a. On 3/7/26 at 07:47 AM, Staff M (ED Physician) documented that P4 presented to the Emergency Department (ED) by ground ambulance with complaints of weakness and falls. Staff M documented that P4 had a past medical history of atrial fibrillation, anemia, coronary artery disease, stage III chronic kidney disease, colon cancer undergoing chemo, hypertension, and acute kidney injury. b. On 3/7/26 at 11:45 AM, Staff D (ARNP) placed an order for P4 to receive 12.5 mg of metoprolol (a beta-blocker medication used to treat high blood pressure and/or high heart rates) at a frequency of ‘BID’ (an abbreviation for the Latin phrase bis in die, meaning “twice a day”). Staff D also placed parameters with this order to not administer the medication if P4’s systolic blood pressure was below 90, if P4’s heart rate was below 50, or if P4 displayed symptomatic hypotension. c. On 3/7/26 at 3:07 PM, Staff D (ARNP) documented a History and Physical for P4. Staff D documented that P4 was admitted to the Advanced Care Unit (ACU) with a primary diagnosis of weakness and neutropenia (a low level of neutrophils, a type of white blood cell, which can occur due to chemotherapy treatment). Staff D documented that P4 would also receive antibiotics. d. On 3/8/26 at 3:15 PM, Staff G (RN) documented that P4 received 2 units of blood due to a low hemoglobin and a low blood pressure of 74/40 mmHg. e. On 3/10/26 at 8:09 AM, Staff H (RN) documented inquiring with Staff A (ARNP) whether or not to administer P4’s morning dose of metoprolol due to P4 having a low blood pressure of 91/55 mmHg (normal blood pressure is approximately 120/80 mmHg). Staff H documented that Staff A had advised holding this dose of the metoprolol due to P4’s low blood pressure. f. On 3/10/26 at 3:28 PM, Staff G (RN) documented that Staff A (ARNP) ordered for P4’s morning dose of metoprolol to be administered due to P4’s blood pressure having risen enough to tolerate a dose of the medication. Staff G also documented a blood pressure of 103/59 mmHg on P4. g. On 3/10/26 at 7:34 PM, Staff J (CNA) documented P4’s vital signs, which included a blood pressure of 106/54 mmHg and a heart rate of 96 beats per minute (BPM) (normal resting heart rate is between 60-100 BPM). h. On 3/10/26 at 8:59 PM, Staff I (LPN) administered P4’s evening dose of 12.5 mg metoprolol as typically scheduled (at 9:00 PM). Staff I documented “Patient Request” as the reason for administering the medication early (approximately 5 hours after the previous administration, and approximately 7 hours earlier than ordered). Staff I did not document assessing P4’s vitals prior to administering the drug. i. On 3/11/26 at 12:01 AM, Staff J (CNA) documented P4’s vital signs for the first time since 7:34 PM on 3/10/26, approximately 4.5 hours prior, and approximately 3 hours since the 2nd dose of metoprolol was administered. Staff J documented P4’s blood pressure as 92/53 mmHg and a heart rate of 89 BPM. j. On 3/11/26 at 12:15 AM, Staff K (RN) documented that P4 complained of shortness of breath and displayed course [sic] lung sounds. Staff K documented that Staff A (ARNP) ordered to stop all intravenous (IV) fluids in response to P4’s symptoms and that Staff A ordered an X-ray of P4’s chest due to possible fluid overload causing said symptoms. k. On 3/11/26 at 1:16 AM, Staff I documented vital signs for P4. Staff I documented a blood pressure of 78/46 mmHg and a heart rate of 96 BPM. l. On 3/11/26 at 2:21 AM, Staff K documented P4’s blood pressure had not improved since stopping IV fluids, and that the chest X-ray did not display evidence of fluid overload. m. On 3/11/26 at 2:31 AM, Staff I documented that P4’s cardiac monitor was “reconnected” at the request of Staff A (ARNP). n. On 3/11/26 at 3:30 AM, Staff K documented P4’s blood pressure as 77/47 mmHg. o. On 3/11/26 at 5:51 AM, Staff K documented P4’s blood pressure as 88/46 mmHg. Staff K documented that Norepinephrine (a vasopressor used to treat severe, acute low blood pressure) was administered to P4 on a continuous IV infusion. p. On 3/11/26 at 6:20 AM, Staff I documented speaking to P4’s family via phone. Staff I documented notifying P4’s family that P4 displayed dangerously low blood pressure. q. On 3/11/26 at 10:54 AM, Staff H documented P4’s blood pressure as 121/57 mmHg. Staff H also documented that Staff D (ARNP) ordered to stop P4’s infusion of Norepinephrine. r. On 3/11/26 at 11:52 AM, Staff H documented that P4 was experiencing confusion and hallucinations. s. On 3/11/26 at 12:31 PM, Staff H documented that Staff D (ARNP) had advised not to worry about P4’s blood pressure unless P4’s systolic blood pressure fell to the 80s or lower. t. On 3/11/26 at 1:41 PM, Staff H documented that P4’s blood pressure was 79/37 mmHg and that P4 displayed worsening confusion. u. On 3/11/26 at 2:30 PM, Staff D (ARNP) completed transfer paperwork, indicating that P4 would be transferred via air ambulance (helicopter) to an acute care hospital due to hypotension and renal (kidney) failure. v. On 3/11/26 at 2:50 PM, Staff H documented that P4’s Norepinephrine infusion would be resumed due to continued low blood pressures. w. On 3/11/26 at 4:39 PM, Staff D (ARNP) completed a discharge summary for P4. Staff D documented, “In review of the chart it was noted yesterday late afternoon patient was given a dose of [P4’s] metoprolol for [P4’s] heart rate >130s; patient unfortunately was given [P4’s] night metoprolol dose 5 hours later which may likely have contributed to [P4’s] hypotension [low blood pressure] this morning that led to start the Levophed drip.” Staff D also reported a steady increase in P4’s creatinine level throughout the day (creatinine is a waste product in your blood, which can be used to evaluate how well the kidneys are functioning. High levels may indicate kidney dysfunction). Staff D also documented that due to P4’s hypotension and rising creatinine level, P4 required transfer to a higher level of care due to suspected cardiogenic shock. Staff D also reported that blood cultures, computed tomography (CT) imaging of the head, and other laboratory testing completed in the afternoon of 3/11/26 were all negative for an acute process that would otherwise explain the sudden drop in blood pressure and unexpected cardiogenic shock. x. On 3/11/26 at 5:40 PM, Staff H documented that P4 departed the CAH via air ambulance transfer to an acute care hospital. 5. During an interview on 5/12/26 at 2:45 PM, Staff B (Nurse Supervisor) reported that all patients admitted to the advanced care unit (ACU) are expected to have vital sign measurements collected once every 4 hours, but staff were expected to assess vitals again prior to administering a medication that could affect the patient’s vital signs, such as metoprolol. Staff B also reported that when a staff member attempts to chart a medication administration more than 60 minutes prior to the scheduled time, a pop-up window would appear on the screen, indicating that the medication was not yet scheduled to be administered. Staff B reported that the pop-up window must be acknowledged prior to completing the documentation of the medication administration, and a reason must be selected from a drop-down list of options to explain why the medication was administered prior to the scheduled time. Staff B indicated that, when seeing this window, staff were expected to pause, review the medication order, re-assess the patient, or notify the hospitalist to inquire if the medication administration would be appropriate prior to administering the medication. 6. Upon review of the CAH’s electronic medical record system, a pop-up window displayed after scanning a medication that was not yet due for administration. The actual scheduled date and time were displayed in the pop-up window, as well as the date and time the medication was scanned. The user was then prompted to “Specify a reason why the medication is being documented early” by selecting an option from a drop-down list. The listed options in the drop-down list included the following: 1. Back-charting an earlier dose, 2. First dose given, 3. Given before procedure/surgery, 4. Given within scheduled time frame, 5. Given with meals, 6. Held for procedure, 7. Medication not available, 8. Nausea/ vomiting, 9. No IV Access, 10. Not Late; previous dose wasn’t charted, 11. NPO, 12. Off nursing division, 13. Patient Request, 14. Physician consultation required, 15. Refused medication, and 16. Other.” 7. During an interview on 5/13/26 at 9:15 AM, Staff I (LPN) reported administering a dose of metoprolol for P4 on 3/10/26 at 8:59 PM. Staff I acknowledged administering this dose of metoprolol despite the most recent set of vitals being taken at 7:34 PM on this date, and despite the patient receiving the same dose of that medication less than 5 hours prior. Staff I reported believing that it was acceptable to use vital signs taken 2 to 3 hours prior to the administration of a drug to determine if a patient met the vital sign parameters at the time of receiving that drug. Staff I acknowledged they should have taken P4’s vitals prior to giving the medication dose at 8:59 PM. Staff I reported the charting system flagged the administration of the dose, and that they had selected “Patient Request” from the drop-down list to explain why the metoprolol was being administered early. Staff I reported being unsure why they had selected “Patient Request” as the reason for administering the dose 7 hours early. Staff I acknowledged that the medication dose was not administered in accordance with the provider’s written order or accepted standards of practice. Additionally, Staff I acknowledged that a Medication Error Report was not filed regarding this event. 8. During an interview on 5/12/26 at 3:30 PM, Staff E (Director of Pharmacy) reported that the peak therapeutic effect of metoprolol would occur in a patient 3 to 4 hours after the medication is administered. Staff E reported P4’s condition began to suddenly decline in the morning of 3/11/26, around the time the metoprolol would have reached peak effect. Staff E reported that P4 received their evening dose of metoprolol at 8:59 PM on 3/10/26 and that P4 first became symptomatic at 12:25 AM on 3/11/26, approximately 3.5 hours after receiving the metoprolol. Staff E reported that expected symptoms of a metoprolol overdose would include low blood pressure and low heart rate. Staff E acknowledged that P4 began to experience an appreciably low blood pressure and a reduced heart rate 3 to 4 hours after receiving metoprolol at 8:59 PM on 3/10/26. Staff E reported that the metoprolol dose administered on 3/10/26 at 8:59 PM may have contributed to P4’s unexpected decline on 3/11/26. Additionally, Staff I reported that a Medication Error Report was not filed regarding this event. 9. During an interview on 5/13/26 at 12:30 PM, Staff D (ARNP) reported that medications ordered as “BID” should be administered once every 12 hours. Staff D reported that, since P4’s morning dose of metoprolol was held on 3/10/26 until 4:00 PM that day, the evening dose should not have been administered until 4:00 AM on 3/11/26. Staff D confirmed that the dose of metoprolol administered on 3/10/26 at 8:59 PM was not administered in accordance with their written order for this medication on 3/7/26. Staff D reported that they had discovered the medication error in the morning of 3/11/26, after reviewing P4’s Medication Administration Record (MAR). Staff D reported reviewing P4’s MAR to identify possible explanations for P4’s unexpected decline in condition. Staff D reported that this medication error could have contributed to P4’s unexpected decline. Staff D also reported that a Medication Error Report was not filed regarding this event. 10. Review of the CAH’s documentation related to a grievance filed on behalf of P4 on 3/23/26, alleging a possible medication error occurred on 3/10/26 and may have contributed to P4’s premature death, revealed that Staff F (Medical Director) reviewed P4’s medical record from 3/10/26 for a potential medication error on 3/26/26. On 3/26/26 at 8:50 AM, Staff F documented that the administration of metoprolol on 3/10/26 at 8:59 PM was not an error, and that the medication was administered appropriately. Staff F cited that the administration was appropriate since P4’s vitals were within parameters at the time of administration. Staff F documented that they would not consider this incident a medication error and that no Medication Error Report was filed regarding this event. 11. During an interview on 5/13/26 at 1:15 PM, Staff F (Medical Director) reported reviewing P4’s medical record (chart) on 3/26/26 in response to a grievance filed on behalf of P4. Staff F confirmed that after their review of P4’s chart, they had concluded on 3/26/26 that the metoprolol was administered appropriately, as the most recent set of vitals prior to the administration were within parameters to receive that dose. However, Staff F acknowledged that they were not aware that the most recent set of vitals was taken approximately 1.5 hours prior to the administration of the dose. Staff F reported that, when reviewing medical records for potential medication misadministration, they would not typically cross-reference the time the medication was administered with the time at which the most recent set of vital signs was taken. Staff F reported that it would not meet accepted standards of practice for nursing staff to use vitals taken approximately 1.5 hours prior to the administration of a drug to assess whether or not the patient met the vital sign parameters to receive the medication. Staff F stated that it would not be possible to determine whether or not P4’s vitals were within parameters to receive a dose of metoprolol at 8:59 PM on 3/10/26 due to there not being a recent set of vital signs. Staff F also reported that BID Medications are ordered to be administered once every 12 hours. Staff F acknowledged that two doses of metoprolol were administered to P4 within 5 hours on 3/10/26, which was not in accordance with the written and signed order for that medication. Staff F further acknowledged that P4’s unexpected drop in blood pressure was within the expected timeframe that metoprolol would have reached peak therapeutic effect on P4’s blood pressure. Staff F stated that P4 may have been overdosed on metoprolol in the evening of 3/10/26, which may have contributed to P4’s overall decline. 12. During an interview on 5/13/26 at 2:00 PM, Staff Q (Nurse Manager) reported that nursing staff were expected to use their clinical judgment when reviewing orders for medication administrations and to notify the provider regarding any concerns they may have with the order. Staff Q reported that medications ordered BID are ordered to be administered once every 12 hours. Staff Q acknowledged that P4’s administration of metoprolol on 3/10/26 at 8:59 PM was not administered according to accepted standards of practice. 13. During an interview on 5/14/26 at 9:45 AM, Staff S (Chief Nursing Officer) reported there were no expectations for nursing staff to assess whether a patient’s vital signs were within parameters to receive a medication prior to that medication being administered. Staff S further reported that, even if that patient had previous doses of a medication held due to the patient’s vital signs not being within parameters, there were no expectations for nursing staff to assess vital signs on that patient prior to the administration of subsequent doses of that medication. Staff S acknowledged that P4’s metoprolol administration on 3/10/26 at 8:59 PM should have been classified as a medication error. Staff S acknowledged that the administration of metoprolol on 3/10/26 at 8:59 PM deviated from accepted standards of practice and was not administered in accordance with the provider’s written order. Additionally, Staff S acknowledged that a Medication Error Report was not filed regarding this event. 14. During an interview on 5/13/26 at 10:15 AM, Staff H (RN) reported caring for P4 on 3/10/26 and on 3/11/26. Staff H reported believing that BID medications do not need to be administered once every 12 hours. Staff H indicated that the only expectation of nursing staff for BID medications is that the medication is just administered twice in one day, regardless of the time between the doses. Staff H reported believing that the administration of metoprolol on 3/10/26 was not a medication error due to the medication only being administered twice in a 24-hour period. Staff H indicated they were unaware that BID medications were expected to only be administered once in a 12-hour period. Staff H indicated that nursing staff were always expected to evaluate vital signs before administering a medication that could affect the patient’s vital signs, such as metoprolol. Review of hospital policies, medical records, and staff interviews revealed nursing staff were unable to recognize that the metoprolol administered to P4 on 3/10/26 at 8:59 PM was administered in error, nursing staff failed to demonstrate knowledge and competency related to BID medication orders, nursing staff administered a dose of metoprolol to P4 outside of accepted standards of practice and not in accordance with written orders, and nursing staff failed to consistently demonstrate knowledge of accepted standards of practice related to assessing patient’s vital signs prior to administering medications.”

“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: 51283 Based on observation, document review, and staff interviews, the critical access hospital (CAH) staff failed to ensure that hospital staff properly stored and labeled prepared food products in the freezer and refrigerator area. The Critical Access Hospital (CAH) reported a census of two patients when entrance was made. Failure to properly label and store prepared food created a risk to patient safety by an increased likelihood of foodborne illness due to potential bacterial contamination from unknown storage times and improper temperatures. It also introduced an increased risk of nutritional errors for patients on therapeutic or specific diets and a lack of traceability in the event of a foodborne outbreak. The absence of proper labeling and documentation hinders the hospital’s ability to identify, isolate, and respond to potential sources of contamination, which could result in poor patient outcomes. Findings include: 1. Review of policy Dietary Infection Prevention, date of last review 10/20/24 revealed: a. Purpose: “... to reduce the risk of transmission of infection among staff, and patients ...” b. Purpose: Equipment and supplies cleaning: “... food and supplies are stored according to food service, safety, and sanitation policies and procedures as outlined in food code 2017 ...” 2. Review of the ServSafe Food Protection Managers certification, 7th additional training, date of last revision 07/01/2023 revealed: a. ... “Labeling food for use on-site:... items not in their original containers must be labeled; food labels should include the common name of the food or a statement that clearly and accurately identifies it...if the item contains two or more ingredients, list the ingredients in descending order by weight; list the artificial colors and flavors in the food including chemical preservatives; list name and place of business of the manufacturer, packer, or distributor; and list source of each major food allergen contained in the food ...” b. ...”Date marking:... if it is held at 41°F (5°C) or lower: the count begins on the day that the food was prepared or a commercial container was opened ...” 3. On 04/30/2025 at 9:00 AM, accompanied by the Food Service Manager and the Chief Nursing Officer (CNO) observation of the kitchen area was conducted, which revealed eight plastic bags of ham balls in the refrigerator/ freezer without proper labeling. 4. On 04/30/2025 at 9:00 AM, during observation, the Food Service manager confirmed the ham balls should have been labeled correctly with the date prepared to ensure proper storage and handling. The Food Service Manager was observed disposing of the unlabeled ham ball containers. 5. On 05/01/2025 at 8:00 AM, during an interview with the hospital Dietician/Food Service Director, it was reported that staff completed a food labeling training on February 27th, 2025. The hospital Dietitian recalled that all kitchen staff have been trained to label prepared items with the name of the item and the date prepared in accordance with the policy for Dietary Infection Prevention. The hospital Dietitian revealed the Sous Chef and the Food Service manager completed the ServSafe Program, which provided staff direction on food safety, labeling and dating to prevent foodborne illnesses.”

“INITIAL COMMENTS 42 CFR 483.90(a) Montgomery County Memorial Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101-2012 edition. Montgomery County Memorial Hospital is a one story building with a full basement of Type 1 (111) construction that was built in 1989. The building is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms and the spaces open to the corridors. Resident rooms have smoke detectors that are connected to the nurse call system. The facility has 25 certified beds, All 25 beds are certified for Medicare/Medicaid only. At the time of the survey the census was 1. The requirement 42 CFR 483.90(a) is NOT MET as evidenced by:”

“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: 51442 Based on observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.2.1.1.1 and Section-5.2.1.1.2), 2011 Edition. These deficient practices affect all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 1. Findings include: Observation and interview on 04/30/25 at 10:42 a.m., revealed in the dishwashing are of the kitchen a sprinkler had excessive corrosion buildup on the sprinkler, arms, and diffuser. Maintenance verified this observation during the survey.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 51442 Based on record review and interview, the facility failed to provide an adequate outage policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.5.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 1. Findings include: Record review and interview on 04/30/25at 10:00 a.m., revealed the provided Sprinkler Outage Policy for the system being out of service for 10 or more hours in a 24 hour period did not designate an Impairment Coordinator. The policy did not address the extent and expected duration of the impairment and that the areas of the building involved have been inspected and increased risks determined. The policy did not address tagging of the impaired system. Nor did the policy address emergency impairments such as system leakage, interruption of water supply, ruptured piping, or other equipment failure. The Administrator and Maintenance Director verified this observation at the time of the survey process.”

“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: 51442 Based on observation and interview, the facility failed to ensure that smoke barriers are free of penetrations which would prevent the passage of smoke to an adjacent smoke compartment in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-8.5.6.2), 2012 Edition. This facility has a capacity of 25 and a census of 1. Findings include: Observation on 4/30/25, at 10:42 a.m., revealed a 1/2 ceiling penetration in the dishwashing room of the kitchen. Maintenance verified this observation during the survey.”

“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: 51442 Based on record review and interview, the facility is not conducting drills on a random basis in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.4), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity 25 and a census of 1. Findings include: Record review and interview on 04/30/25 at 10:28 a.m., revealed the facility failed to vary the times fire drills are conducted. Documentation provided indicates the drills on 2nd shift were consistently being conducted at 2:30 p.m. Administrative Staff and Maintenance Staff verified this observation at the time of the survey process.”