Ringgold County Hospital

“42 CFR 485.623(d) Ringgold County Hospital was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623(d), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 Edition. Ringgold County Hospital is a 1 story building that was built in 2008. The building is composed of Type II - Protected 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 16 certified beds. At the time of the survey, the census was 7. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“Multiple Occupancies - Construction Type CFR(s): NFPA 101 Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 This Standard is not met as evidenced by: 51442 Based on observation, the facility failed to maintain a 2- hour separation in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.3.5), 2012 Edition. This facility has a capacity of 16 and a census of 7. Findings include: Observation on 2/28/25, at approximately 11:12 a.m. revealed a penetration (approximately 1/2 inch) hole next to piping in the two hour rated fire wall of the oxygen storage room. Maintenance Staff verified observations during the survey process.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 51442 Based on observation and staff interview, the facility failed to install components of the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. Smoke detectors shall not be installed near air supply or return ventilation ducts. The facility has a capacity of 16 with a census of 7 patients. Findings include: Observation and staff interview on 2/28/25, at approximately 11:33 a.m., revealed a smoke detector installed within two feet of an air supply or return ventilation duct in the Outpatient Clinic. Maintenance Staff verified observations during the survey process.”

“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: 51442 Based on record review and interview, the facility failed to inspect the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.4.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 16 and a census of 7. Findings include: Record review and interview on 02/28/25 at 10:30 a.m., revealed the generator prints out a daily run receipt that doesn’t have a complete generator weekly or monthly inspection overview. Weekly inspection shall include documentation of the following: 1. Fuel 2. Battery 3. Oil 4. Belts/Hoses **Note the Generator prints out a daily ticket that does not report the aforementioned information** Monthly Load Test Overview: 1. Meter Readings 2. Transfer switch operated 3. Date/Run times 4. Amperages Recorded 5. Meter Start and Stop Times Recorded. **Note CAT Generator Repair provided printout for November and December of 2024. The aforementioned items were not included** Maintenance staff verified this observation during the survey process.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. 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 the staff removed outdated supplies from the: pharmacy, sterile and hazardous compounding area, medical surgical floor, and laboratory area. The Critical Access Hospital (CAH) reported a census of one patient when entrance was made. Failure to remove outdated equipment, cleaning products, and supplies from CAH ’ s storage supply areas and patient care areas, could potentially result in staff using expired supplies and/or products on a patient after the manufacturer’s expiration date resulting in infection risk, malfunctioning of equipment, potentially harmful, toxic or ineffective use of a product, and compromised patient safety leading to infections, improper treatment or exposure to harmful substances. Findings include: 1. Observation during a tour on 2/24/25 at 12:45 PM of the laboratory with the Clinical Laboratory Director, revealed the following: Six universal viral transport media expired on 4/30/24. 2. Observation during a tour on 2/24/25 at 11:30 AM of the pharmacy with the Pharmacy Manager, revealed the following: One box of 40 Equashield syringe units expired on 9/1/24. One box of 40 Equashield syringe units expired on 3/1/24. One box of 40 Equashield syringe units expired on 8/1/23. 40 counts of continuous ambulatory drug delivery (CADD) extension set expired on 8/30/24. 12 counts of CADD extension set expired on 8/22/24. 3. Observation during a tour 2/25/25 at 9:00 AM of the Sterile and Hazard Compounding area of the pharmacy with Staff C Pharmacy Technician, revealed the following: Two open containers of PreEmpt RTU ready-to-use disinfectant wipes expired on 1/2024. Two open containers of ISOA 16-C sterile 70% isopropyl alcohol expired on 6/3/22. 4. Observation during a tour 2/25/25 at 1:46 PM of the medical surgical floor with the Chief Nursing Officer, revealed the following: Four packages of Cables and Sensors Disposable blood pressure transducer, (a single-use medical device used to directly measure arterial or venous blood pressure by inserting a small catheter into a blood vessel) expired on 1/2025. One pair of size 8.5 sterile surgical gloves expired on 4/24. 5. Review of the 3/2024 policy “Sterile Product Compounding - Product Categorization & Establishing Beyond Use Dating” revealed in part: a. ...” The extent to which a product or preparation retains physical and chemical properties and characteristics within specified limits throughout its expiration or [beyond-use date (BUD)].”... 6. Hospital staff did not provide a policy indicating direction for staff to routinely inspect supply and drug outdates. 7. During an interview on 2/25/25 at 9:00 AM, the Infection Control Nurse confirmed staff should not use any expired cleaning products, medical equipment or devices, medication at any time.”

“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: 51283 Based on observation, document review, hospital policy review, and staff interviews, the hospital ’ s administrative staff failed to ensure hospital staff appropriately secured protected health information (PHI) from unauthorized access. The Critical Access Hospital (CAH) reported a census of one patient upon entrance to the facility. Findings include: 1. During observation of the clinical laboratory area on 2/24/25 at 12:45 PM, the survey team identified a large monitor, which displayed PHI of 6 patients, including room number/patient location, lab tests to be drawn, and full first and last names, which remained visible to any individuals entering the laboratory. 2. Review of the 12/2024 policy “Protection of Medical Records” revealed in part: a. ...”Protection of patient health information extends beyond the actual hard copy record to include elements on the Hospital ’ s computer system.”... 3. Review of the 1/2025 policy “Confidentiality of the Clinical Record” revealed in part: a. ...”[Staff] will observe a strict code of confidentiality. Medical information includes all information pertaining to a patient ’ s treatment, diagnosis, lab results, personal affairs, etc., whether written, observed or heard.”... 4. During an interview on 2/24/25 at 12:45 PM, the Clinical Laboratory Director confirmed housekeeping staff and laboratory equipment vendors regularly entered the laboratory to perform cleaning and maintenance services, respectively. Additionally, the Clinical Laboratory Director reported the monitor remained on from 6:30 AM to 10:30 PM. Housekeeping staff typically provide cleaning services for the lab during afternoon hours while lab staff are present. The large monitor that displayed protected health information (PHI) of 6 patients, including first and last names, would be visible to any individuals entering the laboratory. The Clinical Laboratory Director confirmed housekeeping staff and laboratory equipment vendors did not need access to the PHI displayed on the monitor. The Clinical Laboratory Director confirmed the door to access the laboratory is kept unlocked from 6:30 AM to 10:30 PM which allows unauthorized staff or personnel to see the PHI displayed on the monitor. 5. During an interview on 2/25/25 at 12:45 PM, the Chief Clinical Officer confirmed housekeeping staff and laboratory equipment vendors did not need access to the PHI displayed on the monitor.”

“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 infection control protocols and proper safety and hygiene standards were being followed. The Critical Access Hospital (CAH) reported a census of one patient when entrance was made. Failure to separate personal food items from clinical storage areas and eating in clinical areas where laboratory processing with equipment occurs could potentially lead to safety concerns, contamination of sensitive equipment, inaccurate patient samples, cross contamination, increased risk of foodborne illness, exposure to hazardous substations and overall infection control issues. I. Findings include: 1.Observation during a tour on 2/24/25 at 12:45 PM of the laboratory with the Clinical Laboratory Director, revealed the following: a. In the medical grade freezer, one box of Biofire solution (solution used in an laboratory instrument panel to detect and identify the pathogens most commonly associated with respiratory infections) was located on the top shelf of the freezer, on the second and third shelf of the same freezer personal staff food products were found: including frozen prepared meals. b.One staff member was observed eating food at a desk located next to the laboratory refrigerator with laboratory reagents and supplies stored inside; near two chemistry analyzer machines. 2. Review of the policy “Safety Handling Reagents and Patient Samples”, approved 4/24 revealed in part: “No smoking, eating or drinking in the laboratory work area.” 3. During an interview on 2/25/25 at 9:00 AM, the Infection Control Nurse confirmed staff should not eat, drink or have food products by or near the chemical analyzer machines in the lab. The Infection Control Nurse confirmed staff should not store personal food or drink products in clinical refrigerators or freezers used for laboratory materials, specimens, reagents, or solutions. The Infection Control Nurse confirmed staff should store personal food or beverages in designated refrigerators or freezers marked for staff use only. II. Findings include: 1.During a tour on 2/24/25 at 12:30 PM of the Radiology Department computed tomography (CT) room, the Radiology Lead explained oxygen extension tubing attached to the wall oxygen regulatory unit was used for multiple patients and the adapter was changed between patients and their tubing is attached to the new adapter. 2.Review of the CAH ’ s policy, “Respiratory Care Department Infection Control Program”, approved 8/2024, stated “Disposable equipment, single use, prepackaged and sterile, shall be used in the following procedures” ... “Oxygen cannula ’ s, masks, catheters, connective tubing, etc.” 3.During an interview on 2/25/25 at 9:00 AM, the Infection Control Nurse confirmed the oxygen threaded wing nut and barbed nipple configuration device and oxygen extension tubing is single use and should be disposed of and changed between patients. 4.. Review of the manufacturer’s information confirmed the oxygen-threaded wing nut and barbed nipple configuration device (also referred to as a Christmas tree adapter) is a single-patient disposable device.”