Community First Medical Center

“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: 20224 Based on observation, not all portions of the building’s fire alarm system are installed as required. This deficient practice could affect patients, staff, and visitors in the building because they could be unaware of a fire condition if the fire alarm system is not properly installed. The finding is: On 09/23/2024 at 11:20AM while in the company of the FM, it was observed that the 6th floor exit passageway serving the exit stair lacked a manual pull station within 5’ of the passageway entry door to comply with NFPA 72-2010, 17.14.6.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 20224 Based on observation, staff interview, and document review the facility failed to provide maintenance of equipment within the ventilation system. Failure to install and maintain equipment could result in system failure. This deficient practice may affect patients, staff and visitors by not providing adequate ventilation within the environment during a fire smoke incident. Findings include: On 09/23/2024 while in the company of the FM, the surveyor observed multiple portible chiller units thorugh out the facility located within the means of egress. The FM indicated failure of the main chiller unit and subsequent replacement. However, multiple portable chiller units were observed within corridors and other means of egress. There was no documentation available concerning the installation of the new unit. This condition does not comply with NFPA 90A - 2012, 4.2.4, ASHRAE/ASHE standard 170 2008 Section 4, 6.1 and NFPA 101 9.2.1”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 36774 A. Based on observation, document review, and interview, it was determined that for 3 of 3 patients’ (Pt. #7, Pt. #8, and Pt. #9) clinical records reviewed for monitoring, the hospital failed to ensure that patients were monitored, as required, during call system malfunction. Findings include: 1. On 8/19/2024 from 10:30 AM through 12:00 PM, and on 8/20/2024 between 10:00 AM through 11:00 AM, observational tours of the hospital’s Emergency Department (ED) were conducted. The main ED has seventeen rooms: Rooms 1 through 12 and 14 through 18. The ED has a capacity of 27 patients with 17 patients currently on the census. Other than the wall mounted alert call buttons in each of the ED rooms, there was no handheld device/call system that patients can easily access and use to alert nurses or other staff members. 2. On 8/20/2024, the hospital’s ED policy titled, “Policy for Patient Safety and Monitoring in the Emergency Department During Call System Malfunction” (4/2024) was reviewed and included, “To ensure continuous monitoring and safety of patients (in) the Emergency Department (ED) ... during periods when the call system is non-functional ... 2. Patient Assignment: Nurses and medical staff will be assigned specific patients to monitor based on acuity levels and care needs. High-acuity patients (ESI/emergency severity index of 2) will be prioritized for more frequent checks. 3. Routine Checks: High-acuity patients (e.g., those on continuous monitoring, those requiring frequent interventions: Staff must check on these patients at least every 10 minutes. Moderate-acuity patients (ESI of 3) (e.g., stable but needing regular monitoring): - Staff must check on these patients at least every 20 minutes. -Low acuity patients (ESI of 4-5) (e.g., those waiting for diagnostic results or discharge): Staff must check on these patients at least every 30 minutes ... 5. Patient and Family Communication: Patients and their families should be informed of the call system malfunction and reassured that they will be checked regularly. Provide patients with direct line ... to reach the nursing station ... 6. Documentation: All patient checks and observations must be documented in the patient’s medical record, including the time of the check, observations made, and any actions taken ...” 3. On 8/20/2024, the clinical record of Pt. #7 was reviewed. On 8/17/2024 at 1:03 AM, Pt #7 was brought to the hospital’s ED due to chest pain. Pt. #7 was triaged with an ESI of 3. From 8/17/2024 at 1:03 AM through 8/19/2024 at 1:39 PM, there was no documentation that Pt. #7 was checked every 20 minutes, as required. 4. On 8/20/2024, the clinical record of Pt. #8 was reviewed. On 8/19/2024 at 12:45 AM, Pt. #8 was brought to the ED due to suicidal ideation. Pt. #8 was triaged with an ESI of 2. From 8/19/2024 at 12:45 AM through 4:41 PM, there was no documentation that Pt. #8 was monitored every 10 minutes, as required. 5. On 8/20/2024, the clinical record of Pt. #9 was reviewed. On 8/20/2024 at 9:25 AM, Pt #9 was brought to the ED due to back pain. Pt. #9 was triaged with an ESI of 4. From 8/20/2024 at 9:25 AM through 7:00 PM, there was no documentation that Pt. #9 was checked every 20 minutes, as required. 6. On 8/19/2024 and 8/20/2024 at approximately 11:00 AM, interviews were conducted with Pt. #7 and Pt. #9. Pt. #7 stated that there is no easily accessible call system in the room to call for a nurse. Pt. #9 stated, “No one has seen me, and I am in so much pain.” 7. On 8/19/2024 and 8/20/2024 at approximately 1:30 PM, interviews were conducted with MD #1 (Chief Medical Officer) and E #1 (ED Director). MD #1 stated that the absence of patient call lights in the ED has been going on for a while due to a problem in the wiring system. MD #1 stated that there is a plan to change the call light system in the ED but has not identified when that will happen. E #1 stated that staff should be documenting that patients are being checked, as required. E #1 stated that the ED staff have not been documenting the monitoring requirements. 8. On 8/21/2024 at approximately 11:00 AM, E #35 (Lead ED Nurse) verified that there was no documentation for Pt. #7, Pt. #8, and Pt. #9 based on the patient and safety monitoring policy in the ED during call system malfunction. E #35 was not aware regarding the frequency of monitoring documentation requirements. B. Based on document review and interview, it was determined that for 2 of 4 patients’ (Pt #6 and Pt. #7) clinical records reviewed for pain assessment/reassessment, the hospital failed to ensure that pain assessment and/or reassessment was conducted, as required. Findings include: 1. On 8/19/2024, the hospital’s ED policy titled, “Pain Management” (3/2022) was reviewed and required, “... III. Assessment of Pain. 1... a. All patients have their comfort and pain level assessed on admission to the hospital... iii. Utilization of pain rating scale... to record level of pain... C. Reassessment and documentation. 1... b. Within one-hour post pain intervention...” 2. On 8/19/2024 , the clinical record of Pt. #6 was reviewed. On 9/28/2023 at 3:17 PM, Pt. #6 was brought to the ED by Chicago Fire Department (CFD) due to physical assault. The clinical record indicated: - At 3:46 PM, the ED Resident Physician, along with MD #2 (ED Attending Physician) examined Pt. #6. The examination indicated, “ ... (Abdomen): Soft ... no distention. There is tenderness ... (Tylenol was ordered for abdominal tenderness) ...” There was no nurse’s pain assessment for Pt. #6 upon admission to the ED. - At 5:03 PM, Tylenol 650 mg (pain medication) was given to Pt. #6. There was no pain reassessment after administration of Tylenol. 3. On 8/19/2024, the clinical record of Pt. #7 was reviewed. On 8/17/2024 at 12:22 AM, Pt #8 was brought to the ED due to chest pain with a pain rating scale of 6/10 (moderate pain). There was no reassessment of Pt. #8’s pain until 5:46 AM (approximately 5 hours). 4. On 8/20/2024 at approximately 11:00 AM. findings were discussed with E #35 (ED Lead RN). E #35 stated that there should be a pain assessment upon Pt. #6’s admission to the ED, and a reassessment after administration of Tylenol. E #35 also stated that there should be documentation of intervention provided for Pt. #7’s pain, including reassessment within an hour after the intervention.”