Mercyone Centerville Medical Center

“42 CFR 485.623(d) Mercy Once Centerville was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41 B), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition. Mercy One Centerville is a one story building that was build in 1979. 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 spaced open to the corridors. The facility has 25 certified beds. At the time of the survey the census was 6 patients. The requirements at 42 CFR 485.623(d) is NOT met as evidence by:”

“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: 49482 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 fire plan also did not include information on the range hood and how to operate it. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 25 and a census of 6 residents at the time of the survey. Findings include: Record review on 5/7/26 at approximately 12:48 p.m., of the Facilities Emergency Plan and Procedures revealed it did not address information about the range hood and how to operate it. Maintenance Staff confirmed the findings 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 at different times of the day 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. 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 6 residents at the time of the survey. Findings include: Record review on 5/7/26 at approximately 11:20 a.m., of the facility fire drill documentation conducted during 2026/2025 revealed documentation for “who” was involved/participated in the fire drills conducted was not available. Results of the record review were acknowledged by Maintenance Staff at the time of discovery.”

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 50212 Based on medical record review, review of hospital policies and procedures, and interviews with staff, the Critical Access Hospital (CAH)’s administrative staff failed to ensure hospital staff provided timely and necessary ventilatory support for 1 of 10 sampled patients (Patient #3) during a medical emergency, in which the patient became pulseless and lost the ability to breathe spontaneously (without assistance). The cumulative effect of these systemic 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 and procedures and accepted standards of clinical practice.”

“EMERGENCY PROCEDURES CFR(s): §485.635(b)(4) Emergency procedures. In accordance with the requirements of §485.618, the CAH provides medical services as a first response to common life-threatening injuries and acute illness. This Standard is not met as evidenced by: 51283 Based on medical record review, review of hospital policies and procedures, and interviews with staff, the Critical Access Hospital (CAH)’s administrative staff failed to ensure hospital staff adhered to applicable policies and procedures regarding the provision of emergency services for 1 of 10 sampled patients (Patient #3) admitted to the hospital between 2/8/25 and 4/18/25. Failure to provide appropriate emergency services, in accordance with hospital policies and procedures, resulted in delayed positive pressure ventilation (PPV) of Patient #3 (P3) upon cessation of the patient’s breathing. Findings include: 1. Review of the 04/2024 policy “Code Blue” revealed in part: a. “Purpose: To provide guidance during a Code Blue (cardiac or respiratory arrest) situation. Code Blue is an organized response by available staff to the emergent situation of cardiac and/or respirator arrest anywhere in the facility.” b. “Policy: A code blue shall be initiated on any patient who experiences a sudden cessation of vital signs or is in a sudden and unexpected life-threatening situation . . . Trained personnel in the code area will be responsible to start basic life support.” c. “Code Blue Team will consist of the following (if available): the Advanced Cardiovascular Life Support (ACLS) trained emergency department physician . . . The ACLS trained emergency department nurse or paramedic; the ACLS trained respiratory therapist; house supervisor; laboratory staff; the Hospitalist (if in house); assigned nurse of the patient; [and] available clinical staff.” d. “Definitions . . . Advanced Cardiac Life Support (ACLS): a certified training which includes cardiopulmonary resuscitation (CPR), emergent medications, and defibrillation guidelines.” 2. Review of the 2020 American Heart Association (AHA)’s “Basic Life Support Algorithm for Healthcare Providers” revealed the following guidelines for clinical staff: “Look for no breathing or only gasping and check pulse (simultaneously). [If no pulse] perform cycles of 30 compressions and 2 breaths.” 3. Review of Patient #3 (P3)’s 2/11/25 medical record revealed the following: a. On 2/9/25, P3 presented to the emergency department (ED) with increased difficulty breathing, end-stage multiple sclerosis (MS), acute respiratory failure (ARF) with hypoxia (a low level of tissue oxygenation), preexisting Methicillan-resistant Staphylococcus aureus (MRSA) infection, bacteremia (the presence of viable bacteria in the bloodstream, urinary tract infection (UTI), constipation, and a history intellectual disability and multiple other chronic health issues. Per the documentation, the patient’s family member reported the patient experienced choking and aspiration (accidental inhalation of food or liquid into the airway or lungs) while eating prior to the ED encounter. b. On 2/10/25 at 4:34 PM, Staff H (Speech Therapist (ST)) performed a swallow evaluation and documented that the patient displayed signs and symptoms (s/s) of oral phase dysphagia (a condition involving difficulty swallowing), reduced alertness, and difficulty following direction. Staff H provided recommendations for the patient to drink thin liquids via straw, alternating between solids and liquids, and feeding only when alert, at a slow rate, and with total assist and supervision by staff. c. On 2/11/25 at 11:08 AM, staff admitted the patient to the Medical-Surgical (Med-Surg) unit for inpatient observation, speech therapy (ST), and intravenous (IV) antibiotic therapy (ABT). d. On 2/13/25 at 12:59 PM, Staff I (Advanced Registered Nurse Practitioner (ARNP) performed a physical evaluation of the patient and noted the patient continued to experience impaired swallowing and constipation. Staff I documented consideration for nasogastric (NG) tube placement if no improvement in the patient’s condition. e. On 2/13/25 at 8:27 PM, per documentation by Staff E (Registered Nurse (RN)), the patient experienced an episode of emesis (vomiting), a wet-sounding cough, and poor secretion clearance, all of which Staff E noted after the patient swallowed their medications, which staff had crushed into the patient’s pudding. At 8:34 PM, Staff E suctioned the patient with an oral suction catheter and removed a small amount of emesis from the patient’s airway. Staff E noted the patient did not display s/s of distress at this time, and at 8:40 PM, Staff E administered Zofran (an antiemetic medication) for nausea. At 8:42 PM, Staff E identified the patient’s skin began to appear gray, and the patient appeared to not be breathing. Staff E attempted to auscultate (examine by listening) the patient’s lung sounds, which they were unable to detect, and they identified the patient did not have a heartbeat, which prompted the staff member to begin cardiopulmonary resuscitation (CPR). f. On 2/13/25 at 8:44 PM, Staff E called for additional staff assistance and started chest compressions. At 8:45 PM, additional staff arrived and assisted with the resuscitation efforts by administering epinephrine while Staff E continued chest compressions. g. On 2/13/25 at 8:53 PM, Staff O (ED Physician) attempted to intubate the patient unsuccessfully. At 8:55 PM, Staff O again attempted to intubate the patient unsuccessfully. At 8:59 PM, Staff O attempted a third unsuccessful intubation attempt. At 9:01 PM, Staff O successfully intubated the patient after obtaining a camera device aid, and at 9:04 PM, staff identified that the patient had a palpable (tangible) pulse; however, staff identified the patient had sinus tachycardia (elevated heart rate) and did not observe spontaneous respirations at this time. At 9:05 PM, staff applied an endotracheal (ET) tube, and at 9:08 PM, set up a ventilator to manually assist with respirations. Staff R (Hospitalist) requested air transport of the patient via emergency medical services (EMS), which arrived at 10:23 PM to transfer the patient to a higher level of care. h. On 2/13/25 at 9:27 PM, Staff O (ED Physician) documented the following Endotracheal Intubation notes: “Indication: acute respiratory failure . . .Procedure performed: intubation, endotracheal, emergency procedure. Code Blue called . . . I [Staff O] responded as the ED physician on duty. CPR was in progress when I entered the room. Patient was intubated on [fourth] attempt . . . CPR continued until LUCAS was placed, which continued compressions, and patient was bagged via ET tube. Patient was given Epinephrine 1 mg IVP x 3 with return of palpable pulse and sinus rhythm at 106 [beats per minute] . . . Care assumed by [Staff T (Hospitalist)] via Telehealth, and [Staff T] is making arrangements for transfer to [Hospital B].” i. On 2/13/25 at 10:38 PM, staff discharged the patient for transfer to Hospital B via EMS helicopter. j. On 2/14/25 at 7:12 PM, Staff T (Hospitalist) documented the following: “[P3] was admitted to [the CAH] for urinary tract infection. [The patient] developed abdominal distention and was being prepped for colonoscopy. While drink the prep, [the patient] was noted to aspirate. [The patient] was suctioned but did become apneic and lost [their] pulse. A Code Blue was called. [The patient] received a total of 3 mg of epinephrine and 1 amp of sodium bicarb and regained spontaneous return of circulation. [The patient] did get intubated. [The patient] had some difficulty oxygenating but finally did get [their] oxygen saturations in the low 90s. [The patient’s] blood pressure was maintained post Code Blue. [The patient] was transferred by air flight to [Hospital B] for critical care level of care.” k. Review of the medical record revealed, upon cessation of the patient’s breathing, hospital staff failed to provide timely and appropriate ventilation of the patient, in accordance with hospital policies and procedures and accepted standards of practice, during the resuscitation event (Code Blue). Despite multiple unsuccessful attempts to intubate the patient, staff failed to perform an alternative method of ventilation, such as bag-valve-mask (BVM) ventilation (a manual resuscitation technique that provides PPV to patients with inadequate or absent spontaneous breathing), resulting in delayed provision of ventilatory support to the patient during the cardiac event. 4. During an interview on 5/27/25 at 11:30 AM, Staff E (RN) recalled providing P3 with their medication on 2/13/25 (prior to the Code Blue), which the patient reportedly self-administered without difficulty. Staff E reported the patient subsequently had an episode of coughing and emesis, prompting Staff E to suction the patient’s airway and attempt auscultation of lung sounds. Staff E reported administering an anti-nausea medication to the patient, but shortly thereafter, the patient became quiet and pulseless. Staff E reported performing compressions and initiating a Code Blue, and staff continued to document all associated clinical events on an event log during the code. Staff E acknowledged a delay in ventilation occurred during the code, which they attributed to difficulty the provider experienced while attempting to intubate the patient. 5. During an interview on 5/27/25 at 12:30 PM, Staff C (RN) reported assisting with the patient’s resuscitation attempt on 2/13/25. Staff C recalled the provider experienced difficulty intubated the patient, requiring four intubation attempts until correct placement could be secured upon receiving a camera device for assistance with the procedure. 6. During an interview on 5/28/25 at 11:20 AM, Staff O (ED Physician) reported responding to the Code Blue on 2/13/25 for P3. Staff O recalled experiencing difficulty during the attempts to intubate the patient, noting the patient’s comorbidities, which included advanced MS, complicated the intubation process. 7. During an interview on 5/28/25 at 8:10 AM, Staff L (Med-Surg Nursing Manager) acknowledged nursing staff failed to perform and document ventilation of P3 from 8:42 PM (initiation of the Code Blue) to 9:05 PM. Staff L reported nursing staff were expected to immediately begin ventilation of the patient upon initiation of a Code Blue, in accordance with ACLS training receiving by nursing staff, and as required by hospital policies and procedures. 8. During an interview on 5/28/25 at 9:06 AM, Staff M (Chief Nursing Officer (CNO)) reported reviewing the event log for the Code Blue initiated on 2/13/25 for P3, and acknowledged staff failed to perform and document appropriate ventilation of the patient from 8:42 PM (initiation of the Code Blue) to 9:05 PM.”