OSF Saint Paul Medical Center

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 20224 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Recertification Survey conducted on March 6, 2024 , the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated March 6, 2024.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt. #20) reviewed for wound/pressure ulcer assessments, the Hospital failed to ensure that Pt. #20’s pressure ulcer was assessed on admission, in accordance with policy. Findings include: 1. On 2/28/2024, the Hospital’s policy titled, “Elesivir - Ministry Nursing Guidelines” (dated 2024) was reviewed and required, “Wound assessment provides the baseline for planning and evaluating the wound care plan... Information provided in a detailed pressure injury or wound assessment includes: location, type of pressure injury or wound, extent of tissue involvement, type and percentage of tissue in the wound base, size and exudate (description of drainage)...” 2. On 2/29/2024, the Hospital’s policy titled, “Patient Assessment: Initial and Ongoing (1/2023)” was reviewed and required, “Patient assessment ... is performed by the interdisciplinary team and documented in the patient’s electronic health record. Guideline: Within 6 hours of admission, initiate patient assessment including the following: ... Skin risk assessment.” 3. On 2/28/2024, Pt. #20’s clinical record dated 12/26/2023 to 12/27/2023 was reviewed and indicated: -Pt. #20 was admitted to the Hospital on 12/26/2023 with the diagnosis of COVID pneumonia. -Pt. #20’s admission skin assessment noted, “Pt. #20 had sacral pressure injury.” There was no wound assessment documented in Pt. #20’s clinical record regarding extent of tissue involvement, size or drainage of pressure injury. 4. On 2/28/2024 at 11:25 AM, an interview was conducted with the Quality and Safety Coordinator (E #1). E #1 stated that there was no wound assessment documentation for Pt. #20. E #1 stated that there should be an admission wound assessment documented for Pt. #20.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): §485.643(a) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the CAH. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the CAH, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the CAH for this purpose; This Standard is not met as evidenced by: 27125 Based on document review and interview, it was determined that for 2 of 4 (Pt. #14 and Pt. #15) clinical records reviewed for expired patients, the Hospital failed to ensure the organ procurement organization was notified and documentation was included in the clinical record. Findings include: 1. The hospital’s policy titled, “Tissue Organ Donor (4/12/2023)” was reviewed on 2/28/2024 and required, “Tissue donation: ... Patients who have been pronounced dead ... Referral: Before talking to the family, call donor hotline ... Gift of hope will determine the tissues which may be donated. ... Contacting donor hotline and any other actions taken regarding organ/tissue referral will be documented in the patient’s chart in the Post-Mortem Flowsheet” 2. The clinical record of Pt. #14 was reviewed on 2/28/2024. Pt. #14 was admitted on 6/17/2023 with the diagnosis of abdominal pain, shortness of breath and sepsis (severe infection). The discharge summary, dated 6/22/2023 at 7:47 AM included that Pt. #14 expired on the evening of 6/20/2023 (no time). The post-mortem flowsheet indicated that Pt. #14’s time of death was 6/20/2023 at 7:07 PM. The flowsheet indicated that the organ donor network was not notified. 3. The clinical record of Pt. #15 was reviewed on 2/28/2024. Pt. #15 was admitted on 12/20/2023 with the diagnosis of altered mental status. The discharge summary, dated 12/21/2023 at 7:37 AM included that Pt. #15 expired on 12/21/2023 at 6:05 AM. The Post Mortem flowsheet indicated that Pt. #15’s time of death was 12/21/2023 at 6:40 AM per coroner. The post-mortem flowsheet indicated that the organ donor network was notified with a ‘Yes’ answer to the question. The clinical record lacked documentation of the contact person or referral number for the organ donor network. 4. During an interview on 2/29/2024 at 9:00 AM, the Regulatory Coordinator (E#2) stated the organ procurement organization must be notified of all deaths. The person spoken to and the referral number should be documented in the clinical record.”

“RESTRAINT AND SECLUSION CFR(s): The CAH must have written policies and procedures regarding the use of restraint and seclusion that are consistent with current standards of practice. This Standard is not met as evidenced by: 27125 Based on document review and interview it was determined that for 1 of 2 (Pt. #11) clinical records reviewed for patients in violent restraints, the hospital failed to obtain an order for initiation of restraints immediately, per policy. Findings include: 1. The Hospital’s policy titled, “Restraint and seclusion Management (5/2/2023)” was reviewed on 2/28/2024 and required, “Restraints and seclusion are ordered by licensed physicians. ... In an emergency situation, a registered nurse may apply a restraint or initiate seclusion prior to receiving an order. An order is obtained immediately (within a few minutes) following restraint application.” 2. The clinical record of Pt. #11 was reviewed on 2/28/2024. Pt. #11 was admitted on 10/4/2023 with the diagnosis of alcohol abuse. A physician’s order, dated 10/4/2023 at 3:26 PM included hard limb bilateral wrist and ankle for imminent risk of harm to self and others, patient exhibiting violent or aggressive threats/behaviors (violent restraints). The restraint flowsheet indicates that Pt. #11 was placed in violent restraints on 10/4/2023 at 1:15 PM (2 hours and 11 minutes before the order). 3. During an interview on 2/29/2024 at 9:00 AM, the Regulatory Coordinator stated that there should have been an initial order written immediately after restraint initiation.”

“On March 6, 2024 the Life Safety Code portion of a recertification survey was conducted. The surveyor was accompanied during all or a portion of the record document review and the survey walk-through by the following provider representatives: The Facility Planning and Operations Manager (FPOM) Regional Manager of Facility Management (RFM) The building was observed to be one story, slab on grade of Type II(000) construction type and to be fully sprinkler protected. The building was constructed and occupied in the summer of 2011. All portions of the Hospital building were surveyed as Existing Health Care occupancy under the 2012 Edition of NFPA 101 Life Safety Code, including Chapter 19. A Medical Office Building(MOB) is adjacent the Hospital and intended to be separated by 2-hour construction. The MOB is separated by a 2-hour fire rated installation. Unless otherwise noted, those code sections listed herein that do not include a reference to a specific NFPA code and year of issue (such as NFPA 70 2011) are taken from the 2012 Edition of the NFPA 101 Life Safety Code. Unless otherwise noted, all deficiencies cited herein were found through direct observation during the survey walk-through, staff interview, or document review. The requirements of 42 CFR Subpart 485.623 Physical Plant and Environment are NOT MET as evidenced by the deficiencies cited under the following K-Tags.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 20224 Based on observation, the fire pull stations are not properly located. This could affect patients, staff and visitors of the areas served if the fire alarm system does not operate properly during a fire emergency. The finding is: On March 6, 2024 at 12:50pm while in the company of the FPOM and RFM , a manual pull station was observed not located within 5 feet of the designated exit door to comply with 19.3.4.2.1, 9.6.2.3.(2), NFPA 72, 2010, 17.14.5 and 17.14.6. Location observed: The designated disharge vestibule from the ED waiting room contained a pull station located on the backside of the wall between the Waiting room and the Vestibule outside the line of vision.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 20224 Based on observation, not all corridor doors are installed and maintained as required. Failure to maintain corridor doors in accordance with Code requirements could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor if the doors are not properly installed and maintained. The finding is: On March 6, 2040 at 1:15pm while in the company of the FPOM, RFM, the surveyor observed that the Emergency Dept. Trauma room contains a horizontal sliding corridor door installation. This installation did not contain latching hardware to comply with 19.3.6.3.5, 7.2.1.4 4) b) c) i-v.”

“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: 20224 Based on random observation during the survey walk-through, the building’s emergency generator is not installed and maintained to provide the necessary power during a life safety emergency. This deficiency could affectall patients, staff, and visitors in the building because the generators could fail to start under emergency conditions. The finding is: On March 6, 2024 at 11:45am while accompanied by the FPOM and RFM, the surveyor observed the starter batteries for the emergency generators (2 thus) lack an automatically controlled heater /warming blanket. The generator does not appear suitable for the environmental condition at the installation location to comply with NFPA 99, 2012 Edition and NFPA 110 2010 edition section 5.3.1, 5.6.9.2. The manufacturer’s information pertaining to the temperature per cold start and load acceptance were not available for the specific generator model and specification.”