Franklin Hospital

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 51190 Based on a document review and interview, it was determined for 1 of 20 patients (Pt #1) presenting to the emergency department (ED), the Hospital failed to ensure the patient was documented in the Emergency Department Log. Findings include: 1. The ED Log was reviewed from 2/1/25-4/8/25 with the ED Director (E #3) on 4/7/25 at 11:00 AM. There was no evidence that Pt #1 was included on the ED log. 2. On 4/8/2025 a policy titled, “ED Electronic Log (Revised 9/2012) was reviewed. The review revealed, “Each patient presenting to the Emergency Room requesting medical care will be triaged, a chart created and will be entered into the ED Registry Electronic Log.” 3. On 4/7/25 at 1:30 PM an interview was conducted with ED Medical Director/ED Physician (E #9). E#9 was asked if he could recall a patient that presented on 3/1/25 with an eye injury, E#9 remembered (Pt#1). E#9 stated, “(Pt#1) was a Spanish speaking man who came in with (Pt#1’s) brother’s girlfriend. (Pt#1) had a piece of wood in the upper lid of (Pt#1’s) eye, going into (Pt#1’s) eyeball. (Pt#1) appeared inebriated. I (E#9) told (Pt#1’s) brother’s girlfriend, that (Hospital A) can see the patient, but (Pt#1) would be transferred because (Hospital A) does not have ophthalmology. (Hospital A) doesn’t even have a slit lamp (machine that examines eye structure). I (E#9) told the (Pt#1’s) brother’s girlfriend that (Pt#1) would either be transferred to (three other outside facilities named), and as soon as (Pt#1’s brother’s girlfriend) heard the word ‘transfer,’ (Pt#1’s brother’s girlfriend) yanked (Pt#1) away and out of the hospital. We (Hospital A) did not log (Pt#1) into the ED log but should have.” E #9 verbally agreed that the Facility did not log in Pt#1.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 51190 Based on document review and interview, it was determined that in 1 of 20 (Pt #1) Emergency Department (ED) records reviewed, the Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE). Findings include: 1. The policy titled, “EMTALA Medical Screening (Revised 3/2021)” was reviewed. The policy noted, “ ... General requirements A. In general when an individual comes by him or herself or with another person to the Emergency Department of the Hospital, and a request for a medical examination or treatment is made by the individual or on the individual’s behalf, the Hospital must provide an appropriate medical screening examination within the capability of the Hospital’s Emergency Department, including ancillary services routinely available to the Emergency Department to determine whether an emergency medical condition exists, or with respect to a pregnant woman having contractions whether the woman is in labor ... B. The Hospital is obligated to perform the medical screening examination to determine if an emergency medical condition exists. It is not appropriate to merely ‘log in’ a patient and not provide a medical screening examination ... E. The hospital must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with emergency medical conditions who come to the hospital for examination and treatment. F. All refusals for medical screening or leaving without being seen shall be documented in accordance with the Hospital’s Against Medical Advice policy. Such documentation should include a statement that the patient was informed by hospital staff of the risk and benefits of being screened and the types of examinations refused. All reasonable steps to secure refusal in writing will be made.” 2. The ED Log was reviewed from 2/1/25-4/8/25 with the ED Director (E #3) on 4/7/25 at 11:00 AM. Pt#1 was not included on the on log. A request was made for Pt#1’s record at Hospital A. No record was provided as Pt#1 was not included on the ED log and was never registered at Hospital A. There was no medical screening exam (MSE), no lab work completed, or any other treatment/stabilization done for Pt#1. During the log review, E #3 confirmed that Pt #1 was included on the ED Log and had never been registered. Therefore Pt #1 had no medical screening exam, no testing and no treatment completed. 3. Pt#1’s record at Hospital B was reviewed throughout survey. Pt#1 arrived by car on 3/1/25 at 12:11 PM for eye trauma. The ED RN triage note (by complainant) on 3/1 at 12:21 PM stated, ’”I was cutting some trees and a branch hit me (Pt#1) in my eye.’ Patient (Pt#1) presents with laceration to his left eyelid with tissue protruding out. No LOC (loss of consciousness) reported.” Pt#1’s acuity was noted as emergent and a Medical Screening Exam was completed at 12:23 PM by an ED Provider. The ED Provider at (Hospital B) noted, “Eye Trauma: Location: Was cutting tree and a twig got impaled in left eye through eyelid. Severity: Severe ... Duration: 1 hour ... Physical Exam: ... (record showed diagram image of left eye with wording) laceration unable to open lid ... Medical Decision Making: CT (computed tomography) of the orbits with contrast: ... Impression: Nondisplaced fracture of the left frontal sinus/superior extraconal orbit and associated small left frontal extra-axial hematoma and pneumocephalus. Pt#1 received antibiotics and pain medication while in the ED at Hospital B. ED MD contacted (Hospital C - Trauma Center) to arrange transfer at 1:47 PM. Pt #1 was then transferred by helicopter to Hospital C (higher level of care) at 2:02 PM. 4. On 4/7/25 at 1:30 PM, an interview was conducted with (Hospital A) ED Medical Director/MD (E#9). E #9 was asked if he could recall a patient that presented on 3/1/25 with an eye injury, E#9 remembered (Pt#1). E#9 stated, “(Pt#1) was a Spanish speaking man who came in with (Pt#1’s family). (Pt#1) had a piece of wood in the upper lid of (Pt#1’s) eye, going into (Pt#1’s) eyeball. There was nothing I could do as the wood was in the orbital socket, and it would be malpractice to touch it. There was nothing to stabilize.” E #9 confirmed that no MSE was completed and no care was provided to Pt #1 at Hospital A.”

“DRUG AND BIOLOGICALS CFR(s): Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. This Standard is not met as evidenced by: 39025 Based on observation, document review, and interview it was determined the facility failed to ensure expired medications were not available for patient use. The Findings Include: 1. On 10/28/24 at 11:30 AM, during a tour of the emergency department the following medications were found to be expired: -1 of 1 Protamine Sulfate 250 mg/25 ml - 10 mg per ml (single dose vial) - expiration date 09/24. -1 of 1 Norepinephrine Bitartrate 4 mg/4 ml - expiration date 8/24. -2 of 2 Neomycin and Polymyxin B Sulfates and Gramicidin Ophthalmic Solution - 10 ml each - 1 bottle expiration date 8/24, and 1 bottle expiration date 9/24. -1 of 1 Embroil for oral suspension 250 mg/5 ml - expiration date 8/24. -5 out 5 Nabumetone 500 mg/1 tab, expiration date 3/31/24. -1 of 1 Torsemide 100 mg/1 tab - expiration 4/24. 2. An undated Policy titled, “Outdated Drug Control” was reviewed. The policy included, “Policy: Outdated drugs will be removed from stock and will either be returned for credit or properly disposed of. Purpose: Extreme care must be exercised that no outdated medications are dispensed for patient use or allowed to remain in the dispensing area of the Pharmacy or in other medication areas. Procedure: ... 2. The Pharmacy personnel will constantly check all medication physically for dated items and remove all outdated ...” 3. An interview was conducted on 10/30/24 at 12:43 PM with E #6 (Pharmacist). E #6 stated they “do not audit every single medication in the Omni-cell dispensary machine every month. We noted there was a discrepancy with the expiration reports and medications that were not showing they were expired. We have been working on this since August.””

“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: 42887 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on November 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 November 6, 2024, the life safety code portion of the re-certification survey was conducted. The surveyor was accompanied during the survey walk-through by the following provider representative: Director of Engineering (DOE) The Hospital was observed to consist of a 3 story building, constructed in 1955. The building, with the exception of the 1 story north portion of the building, was observed to be of Type I (332) construction (partially sprinkler protected). The north, 1 story portion of the building was observed to be of Type II (000) construction (fully sprinkler protected), but was observed to be separated from the remainder of the building by minimum 2 hour fire rated construction. The facility was surveyed as an existing health care occupancy under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 19. 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 random 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.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 42887 Citation Text for Tag 0311, Regulation K307, Bld 01 Based on direct observation, not all stair doors are maintained to provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the stair door did not provide the proper protection during a fire emergency. The finding is: On November 6, 2024 at 12:30pm, while in the company of the DOE it was observed that the East Exit Stair door on the 3rd floor failed to self-close and self-latch. The door leaf was observed to drag along the door frame to prevent closure. This does not comply with the requirements of Table 8.3.4.2 and NFPA 80, 2010 6.4.1.1.”

“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: 42887 Based on direct observation, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous area from required means of egress paths can compromise the safety of all occupants. Findings include: A. November 6, 2024 at 1:00pm, while in the company of DOE it was observed that the room on the north side of the corridor at the end of the 2nd floor east wing is used for storage, and the doors serving the room are not selfclosing fire rated door assemblies. Therefore, this hazardous area failed to comply with 19.3.2. B. November 6, 2024 at 1:05pm, while in the company of DOE it was observed that an above ceiling penetration in the soiled utility room adjacent to the 2nd floor east wing nurses’ station was not sealed against fire in the fire barrier as shown on the Life Safety plans provided by the facility. This penetration does not comply with 8.3.5.1.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 42887 Based on document review the fire alarm system is not being inspected, tested and maintained in accordance with code requirements. Failure to properly inspect, test and maintain the fire alarm system can result in failure of the system to operate as intended to warn occupants of a fire/smoke event. Findings include: On Novemebr 6, 2024, at 12::00pm while in the company of the DOE, it was observed that the October 15, 2024 annual fire alarm inspection indicated that 7 initiating devices tested outside the manufacturer’s specified sensitivity ranges. No evidence was presenbted to indicate corrective action had occured. Therefore, the system is not maintained in accordance with NFPA 72-2010.”

“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: 42887 Based on document review the facility failed to perform the required sprinkler system maintenance. Failure to maintain the sprinkler system can result in failure or dimminished system performance during a fire event risking the safety of patients, staff and visitors. The finding is: On Novemebr 6, 2024, at 11:45pm while in the company of the DOE, review of the October 15, 2024 annual inspection indicated 4 deficiencies in the sprinkler system; 1 deficiency cited incorrect installation of sprinkler heads, 1 deficiency cited no hose valve inspection, and 2 deficiencies cited gauge replacement/recalibration. No evidence of corrective action was presented for review. Therefore, the system is not maintained in accordance with NFPA 25-2011.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 42887 Based on observation and document review the facility failed to maintain life safety code protective devices. This deficient practice may affect all patients, staff and visitors within the building should a component of an essential system fail during a fire event. The finding is: On Novemebr 6, 2024 at 11:30am, while in the company of the DOE no documentation or evidence of inspection or testing within the previous six years was available for review to comply with NFPA 80-2010, 19.4 and NFPA 105-2010, 6.6.3.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems 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. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 42887 Based on direct observation the facility lacks complete electrical bonding of the medical gas piping system. Failure to install and maintain this installation could potentially result in the piping system becoming electrically energized. This deficient practice could affect patients, staff and visitors. Findings include: On November 6, 2024, at 2:30pm while in the company of the DOE, it could not be confirmed through direct observation that electrical bonding of the facility’s medical gas piping system has been completed. This is not in compliance with NFPA 70-2011 Edition, Section 250.104 (B).”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3 This Standard is not met as evidenced by: 42887 Based on direct observation the generators are not installed as required. This deficient practice could affect patients, staff, and visitors in the building if the generators are not capable of being safely operated as required in an emergency event. The finding is: On Novmeebr 6, 2024, at 2:00pm while accompanied by the DOE it was observed that a manual emergency stop station for generator #2 was remotely located from the prime mover, however, a manual emergency stop station for generator #1 was not observed remotely located from the prime mover as required. This does not comply with NFPA 101-2010, Section 5.6.5.6.”