St Mary Medical Center Inc.

“An investigation of Complaint Number IN00469240 was conducted by the Indiana Department of Health in accordance with 42 CFR 482.41(b). Complaint Number IN00469240 - A Federal deficiency related to the allegation was cited at K161. Survey Date: 05/20/26 Facility Number: 005786 Provider Number: 150034 AIM Number: 100268660A At this Life Safety Code survey, St. Mary’s Medical Center was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies. The facility located in two buildings identified as the East and West towers. The East tower was the original building and five stories; the West tower was six stories and added later. The facility was surveyed as one building in accordance with LSC Chapter 19, since the construction dates of both buildings were prior to March,1 2003. The buildings were both determined to be of Type II (000) for East Tower and Type I (332) for West Tower and were fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 52726 Based on record review, interview, and observation, the facility failed to provide the building construction type that met NFPA 101, Life Safety Code, 2012 Edition. LSC Section 19.1.6.1 requires that health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1. This deficient practice affects 85 of 170 patients, staff and visitors in the East Tower Findings include: Based on record review with Director of Engineering, Engineering Regulatory Compliance Coordinator and Construction Manager on 05/20/26 from 11:00 AM to 12:25 PM, the facility presented a copy of Hospital Construction Floor Plans titled “NFPA 101 Life Safety Plan” to demonstrate the type of construction for East and West Tower. The Hospital Construction Floor Plans for East Tower indicated a building construction type of Type II (000), which was not permitted with Table 19.1.6.1 and was not in compliance with the Life Safety Code building construction type requirements for a five-story building. During an interview conducted at the time of the records review, the Director of Engineering and Construction Manager stated that the facility is currently performing fireproofing spray applications to the unprotected steel structural components as part of ongoing renovations. Furthermore, during observations with Director of Engineering, Engineering Regulatory Compliance Coordinator and Construction Manager on 05/20/26 from 12:30 PM to 12:56 PM, above the ceiling tiles on the fourth floor (4F) near the elevator lobby, the unprotected steel structural support joist/beams were exposed and did not meet the required minimum construction type. During an interview conducted at the time of the observation, the Director of Engineering, Engineering Regulatory Compliance Coordinator and Construction Manager acknowledged the aforementioned condition and stated that they are working to achieve compliance requirements by applying fireproofing spray applications during the renovation process. This finding was reviewed with the Director of Engineering, Engineering Regulatory Compliance Coordinator and Construction Manager during the exit conference. This federal tag relates to complaint number IN00469240.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 14445 Based on document review and interview, nursing services failed to place a wound care consult for an at risk patient, for 1 of 10 MRs (Medical Record) reviewed. (Patient # 2). Findings include: 1. Review of established policy titled: Pressure Injury Prevention Assessment and Treatment, Policy number: SMMC.PCS-P 1.0, indicated on page 3, under Protocol for Consulting Wound Care Nurse Team, 7.0, 3rd point, indicated Any patient with a Braden score <=14 will be seen by Wound Care Services (consult to be placed). Last effective date 3/2025. 2. Review of Patient # 2 MR, indicated, the following: (a). Nurse flowsheet on 2/8/2025 for patient’s admission reflected Braden score = 13 (moderate risk), and included, but not limited to: On 2/9/2025 - Braden score = 13. On 2/13/2025 - Braden score = 13. (b). Wound care nurse note on 2/17/2025 - by N # 22 (RN {Registered Nurse} - Wound care nurse) reflected patient seen for impaired skin integrity related to pressure. Present on admission: No. Pressure injury location: Sacrum. Wound classification: full thickness. Stage: 3. Length = 5 cm (centimeter), width = 3 cm, depth = 0.2 cm. 3. In interview on 6/12/2025 at approximately 3:49 pm, with N # 22, confirmed that no wound consult prior to 2/15/2025, when patient # 2 had lower braden score. 4. In interview on 6/12/2025 at approximately 4:15 pm, with A # 3 (Chief Nursing Officer), confirmed that Policy for pressure injury prevention not followed for wound care consult for patient’s braden score of 14 or below.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 35731 Based on document review and interview the facility failed to ensure a patient’s pain was assessed per policy, skin care intervention was performed and Braden scores were completed accurately for one (1) of ten (10) medical records (MRs) reviewed. (Patient # 10) The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 35731 Based on document review and interview the facility failed to ensure a patient’s pain was assessed per policy, skin care intervention was performed and Braden scores were completed accurately for one (1) of ten (10) medical records (MRs) reviewed. (Patient # 10) Findings include: 1. The hospital policy titled, Assessment of Patients, Policy/Procedure Number: PCS - A, indicated on page 4, section 1.2 - a patient should should be assessed every four (4) hours while on the Intermediate Care Unit (IMCU) and/or Intensive Care Unit (ICU). This policy was last revised in 03/2023. 2. The hospital policy titled, Pain Assessment and Management PC 01.02.07, Policy/Procedure Number: ADPC 16.1, indicated on page 5, Evaluation (Reassessment) section 1.0 - to use an appropriate standard pain scale for assessing pain. Reassess pain level within 60 minutes of an intervention. This includes medications given regularly scheduled. This policy was last revised on 04/13/2022. 3. The hospital policy titled, Pressure Injury Prevention, Assessment and Treatment, Policy/Procedure Number: PCS-P 1.0, indicated on page 1, Background section 4.0 - patients at a greater risk for pressure injury development include, but are not limited to, any patient with a Braden score of 18 or below. On page 3, Evidence Based Interventions specific to Risk Assessment under Mobility (1-4 Braden Scale). Ensure all medium and high risk patients are turned on a regular schedule every two (2) hours. This policy was last revised in 02/2023. 4. Patient # 10 MR review: a. Skin assessment flowsheets dated 12/10/2024 through 12/31/2024, lacked documentation the patient was repositioned on the following dates/time: 12/22/2024 at 6:00 am, 8:00 pm; 12/23/2024 at 2:00 am, 6:00 am, 8:00 pm; 12/27/2024 at 2:00 am, 6:00 am; 12/28/2024 at 10:00 pm; 12/29/2024 at 6:00 pm; and 12/30/2024 at 2:00 am. Wound note dated 12/17/2024 at 10:20 am, indicated skin assessment completed with left gluteus stage 2 measuring 3.8 cm (centimeters) in length, 1.6 cm width, and 0.1 cm in depth. b. The Braden daily flowsheet indicated the patient’s score was documented as 14 (moderate risk) on 12/10/2024. Braden daily flowsheet indicated the patient’s score was documented as 14 (moderate risk) on 12/22/2024 despite the fact the patient had developed a pressure ulcer. The Braden daily flowsheet indicated a patient score of 12 - 13 (high risk) until discharge to the rehabilitation unit on 12/31/2024. c. Pain assessment flowsheet dated 12/26/2024 at 12:55 pm, indicated the patient rated his/her right leg pain an eight (8) out of ten (10). The patient was administered pain medication. The patient’s pain was reassessed at 3:52 pm; at that time the patient indicated his/her right leg pain was an eight (8) out of ten (10). The patient was administered pain medication. The patient’s pain was reassessed at 9:28 pm, and at that time indicated his/her pain was zero (0). The pain flowsheet lacked sixty (60) minute reassessments at 1:55 pm, 4:52 pm and the four (4) hour pain assessment which was due 7:52 pm. 5. In interview on 01/30/2025 at approximately 11:30 am with A # 2 (Systems & Regulatory Quality), confirmed patient # 10’s pain was not assessed according to the policy. His/her pain should have been reassessed sixty (60) minutes after an intervention such as pain medication administration. 6. In interview on 01/30/2025 at approximately 12:45 pm with N # 1 (Registered Nurse-RN/Intermediate Care Unit Manager), confirmed pain should be assessed every four (4) hours, and pain reassessment should be performed sixty (60) minutes following an intervention such as medication administration. All interventions should be charted in the flowsheet. 7. In interview on 01/30/2025 at approximately 2:15 pm with A # 2, confirmed patient # 10’s Braden Score was 12 - 13 (high risk) which would initiate (per protocol) turning the patient every two (2) hours.”