Myrtue Medical Center

“42 CFR 483.90(a) Myrtue Medical Center 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. Myrtue Medical Center is a two story building with a partial basement that was built in 1954 with additions in 1968 and 2024. 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 483.90(a) is NOT MET as evidenced by:”

“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: 42934 Based on observations and interviews, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2. This deficient practice affects all staff within the Kitchen. The facility had a capacity of 25 patients and a census of 3 at the time of the survey. Findings include: Observation on 11/21/2024 at 12:02 p.m., revealed the Food Pantry Room within the Main Kitchen was not equipped with a self-closure device. This food pantry room measured approximately nine feet by twelve feet floor space. The Maintenance Director confirmed this observation at the time of the survey.”

“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: 42934 Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2012 edition. This facility had an enclosed courtyard without a horn/strobe warning device. The deficient practice affects all occupants who may be in this area. This facility has a capacity of 25 with a census of 3 residents. Findings include: Observation and interview on 11/21/2024 at 11:38 a.m., revealed the enclosed Healing Garden Courtyard did not have an exterior horn/strobe device. The Maintenance Director verified this observation at the time of this survey.”

“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: 42934 Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. The facility had a capacity of 25 and a census of 3 at the time of the survey. Findings include: 1. Observation on 11/21/2024 at approximately 11:18 a.m., revealed the facility failed to maintain the sprinkler system near the Outpatient Surgery- Nurse’s Station. The two sprinkler heads located near the desks area contained a large amount of accumulated dust. 2. Observation on 11/21/2024 at 12:04 p.m., revealed the facility failed to maintain the sprinkler system in the Kitchen. The sprinkler heads throughout this area contained an excessive amount of accumulated dust. 3. Observation on 11/21/2024 at 12:08 p.m., revealed the facility failed to maintain the sprinkler system in the Sprinkler Riser Room. The red metal box for stored extra sprinkler heads did not contain the required sprinkler head wrench. 4. Observation on 11/21/2024 at 10:00 a.m., revealed the facility failed to maintain the sprinkler system by not having documentation of quarterly inspections by Associated Fire Protection. A phone call to Associated Fire Protection indicated they had not conducted these inspections. 5. Observation on 11/21/2024 at 10:00 a.m., revealed the facility failed to maintain the sprinkler system by not have the required 5 year internal pipe inspection performed on time. The 12/13/2023 inspection paperwork from Associated Fire Protection mentioned in the note section that the fire year inspection was due. The Maintenance Director confirmed these observations at the time of 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: 42934 Based on record review, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 25 and a census of 3 residents at the time of the survey. Findings include: Record review on 11/21/2024 at 10:20 a.m. of the fire watch procedures for a sprinkler system outage in the facility’s outage policy, revealed the policy was missing. The facility provided a sample policy from Lake Regional Healthcare, but they had not retyped this sample form for Myrtue Medical Center and incorporated the necessary information required in this policy including: 1) Extent and expected duration of the impairment have been determined. 2) The areas or buildings involved have been inspected and increased risks determined. 3) Recommendations have been submitted to management or the property owner. 4) Where the system is out of service for more than 10 hours in a 24 hour period, the impairment coordinator shall arrange for one of the following: a) Evaluation of the building or portion of the building affected by the outage. b) An approved fire watch. c) Establishment of a temporary water supply. d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to a fire. 5) The fire department has been notified. 6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. 7) The supervisors in the areas to be affected have been notified. 8) A tag impairment system has been implemented (See Section 15.3) 9) All necessary tools and materials have been assembled on the impairment site. Sprinkler system outage policy addresses outages due to: system leakage, interruption of water supply, ruptured piping and equipment failure. In addition, the sprinkler system outage policy must state contacting the following agencies at the beginning of implementing a fire watch and when the system is restored to normal: -State Fire Marshal office and phone number -Department of Inspections, Appeals and Licensing and phone number -Insurance provider and phone number -Local Fire Department and phone number. Person performing the fire watch duties must perform the watch “continuously” and completed rounds at least every 30 minutes and be “dedicated” to the watch with no other responsibilities during this assignment. The Maintenance Director verified the documentation at the time of the survey process.”

“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: 42934 Based on observation and interview, the facility failed to ensure the building’s electrical system, wiring, and equipment are in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.1.2 and NFPA 70, National Electrical Code, 2011 edition, 110.26, by not providing or maintaining access and working space about electrical equipment. This deficient practice affects one of nine smoke zones. This facility had a capacity of 25 and a census of 3 residents at the time of the survey. Findings include: 1. Observation on 11/21/2024 at 11:32 a.m., revealed a items stored in front of the electrical panels in the Electrical Closet adjacent to the Fire Alarm Panel Room. 2. Observation on 11/21/2024 at 11:58 a.m., revealed the faceplate on an electrical box for the water flow detection had been removed and not replaced on the box. This box was located outside the elevator D service room door. 3. Observation on 11/21/2024 at 11:24 a.m., revealed two electric clothes dryer vent tube sections were secured with gray duct tape. This duct tape needs to be removed and replaced with approved clothes dryer tape. The Maintenance Director verified these observations during the survey.”

“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: 42934 Based on interview and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1/19.7.1 and 18.7.2/19.7.2. The deficient practice affected all smoke zones and 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 11/21/2024, at 10:37 a.m. revealed the fire plan did not address the following information: The plan did not address all the types of fire extinguishers located in this facility: (ABC, K-Type and the Ansul range hood suppression system) and the use of these extinguishers. The Maintenance Director verified this finding at the time of 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: 42934 Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 25 and a census of 3 residents at the time of survey. Findings include: 1. Record review and interview on 11/21/2024 at 9:44 a.m. of the facility’s fire drill documentation, revealed the facility failed to sufficiently vary the time of fire drills during the first shift (7:00 a.m. - 7:00 p.m.) for the four quarters of 2024. The first shift, first quarter drill was conducted on 01/10/2024 at 7:10 a.m., the first shift, second quarter drill was conducted on 04/10/2024 at 8:00 a.m., the first shift, third quarter drill was conducted on 09/05/2024 at 9:00 a.m. and the first shift, fourth quarter drill was conducted on 10/30/2024 at 9:30 a.m.. In addition, the facility needs to ensure all staff members participating in the fire drills sign in on the rooster as being present for this training. 2. Record review and interview on 11/21/2024 at 9:44 a.m., revealed the overnight shift fire drill testing was not complete. During overnight shift drills, ensure the next day shift testing of the time of fire alarm, signal received and monitoring company information is documented on the previous overnight fire drill paperwork. The Maintenance Director verified the documentation during the survey process.”

“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: 42934 Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms or where patient care may be provided as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects all residents, staff, and visitors in the affected areas. The facility had a capacity of 25 and a census of 3 residents at the time of the survey. Findings include: Record review and interview on 11/21/2024 at 10:20 a.m., revealed the facility provided documentation of hospital-grade receptacle testing upon installation, repairs or modifications for the electrical receptacles in patient rooms. The facility had not maintained or could provide documentation for hospital-grade receptacle testing for other areas of this facility where patient care may be provided. The Maintenance Director confirmed this finding at the time of the survey.”

“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: 48530 Based on observation, hospital policy review and staff interviews, the critical access hospital (CAH) failed to ensure hospital staff safeguard the confidentiality of patient medical record information against the potential of unauthorized access/use of the information through unsecured patient medical record information in open shred bins in the Laboratory Department and Health Information Management Department (HIM), along with unsecured fax machines after hours that may receive patient medical record information including orders in the Rehabilitation Therapy Department, Myrtue Access Center office, and the Diabetic Education office area. The CAH reported an average census total of 540 patients per week in the outpatient Specialty Clinic/Rehabilitation areas, and a daily average census of 7 patients per day in the CAH inpatient areas. Failure to ensure CAH staff safeguard the confidentiality of patient medical record information against the potential of unauthorized access/use placed patients at risk for loss of privacy and theft of their protected health information. Findings include: 1. Review of the hospital ‘s policy, titled “Employee Access to PHI”, last reviewed 2/2024, revealed “... Access to patient records is limited to authorized business purposes only ... ... Myrtue Medical Center workforce has a duty to protect protected health information ...”. 2. On 11/18/24 at 3:30 PM, observation during a tour of the Laboratory Department with Staff C revealed the Laboratory Department was located in the basement of the hospital, with one locked door that had badge access. Observation in the Laboratory revealed one unsecured open wastebasket (with a taped piece of paper that had typed “Shred” on it) that was full to the top of patient information. During an interview 11/18/24 at the time of the tour, Staff C explained staff place papers with patient information in the wastebasket and the information was gathered once a week by Environmental Services (EVS) and taken to a locked shred bin until the contracted shredding company came to remove it. Staff C confirmed the unsecured shred wastebasket had potential for unauthorized persons to gain access to the patient healthcare information. During an interview 11/19/24 at 8:25 AM, EVS Manager confirmed the unsecured shred wastebasket was emptied weekly in the Laboratory area and taken to a locked shred bin until the contracted shredding company came to remove it every 4 to 6 weeks. 3. On 11/19/24 at 10:45 AM, observation during a tour of the hospital ’ s Diabetic Education Nurse ’ s office area with the Diabetic Education Nurse revealed 1 unsecured fax machines after hours that may receive patient medical record information including orders in the Diabetic Education Nurse ’ s office area. 4. On 11/19/24 at 12:45 PM, observation during a tour of the hospital ’ s outpatient Specialty Clinic with the Director of Specialty Clinics revealed 2 unsecured fax machines after hours that may receive patient medical record information including orders in the Rehabilitation Therapy Department, and the Myrtue Access Center office. During an interview on 11/19/24 at the time of the tour, the Director of Specialty Clinics confirmed the unsecured fax machines had potential for unauthorized persons to gain access to the patient healthcare information after hours. 5. On 11/19/24 at 2:25 PM, observation during a tour of the hospital ’ s Health Information Management (HIM) Department with the HIM Supervisor revealed 1 unsecured open cardboard box under the HIM Supervisor ’ s desk they place any documents with patient information in it, that was half full. During an interview on 11/19/24 at the time of the tour, the HIM Supervisor explained they place papers with patient information in the open box and the information was gathered once a week by Environmental Services (EVS) and taken to a locked shred bin until the contracted shredding company came to remove it. The HIM Supervisor confirmed the unsecured shred wastebasket had potential for unauthorized persons to gain access to the patient healthcare information. 6. During an interview 11/19/24 at 4:00 PM, the CNO further explained maintenance staff would be the only other staff who had access to the Laboratory Department, HIM Department, Rehabilitation Therapy Department, Myrtue Access Center office, and the Diabetic Education office area after hours.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 48530 Based on observations, policy review, and staff interviews, the critical access hospital (CAH) administrative staff failed to ensure the hospital ’ s kitchen staff adhered to pertinent policies and procedures of the hospital for 4 of 4 patients in which the survey team observed meal preparation and tray plating. Failure to adhere to policies and procedures set forth by the hospital ’ s administrative staff could result in the provision of reduced quality of care and patient safety, foodborne illnesses and infections, cross contamination of harmful pathogens which could include a deterioration in health, disability, or death. The CAH identified an average of 7 patients receiving kitchen staff meal plating in an inpatient setting per day. Findings include: 1. Review of the hospital ‘s policy, titled “Food Handling and Preparation”, last rviewed 8/2024, revealed “... Employees will use thongs or plastic gloves when handling individual items of foods that will not be further cooked. Employees will be educated on proper glove use upon hire and at least annually at dietary department in-services ...”. 2. On 11/19/24 at 11:50 AM, observation during a tour of Foodservice found the Staff S plating beverages without gloves, and placing beverages on patient trays without gloves. The primary kitchen cook plated hot food items, with gloves, however removed them to use a writing pen and then proceeded to scoop out pureed food from the blender, and used a measuring collection device to obtain liquid from the meat reservoir to add to the pureed container without gloves. Additionally, the primary kitchen cook placed a lid on the pureed meat container, without gloves. 3. During an interview on 11/19/24 at the time of the tour, the Registered Dietitian confirmed all kitchen staff should wear gloves throughout the entire food preparation process. The Registered Dietician further explained it was against policy to dip the measuring device to obtain the liquid from the meat without wearing gloves.”