Northern Light Mayo Hospital

“RESTRAINT AND SECLUSION CFR(s): All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to ensure restraint orders specified which limbs were to be restrained for one (1) out of six (6) restrained patient records reviewed (Patient #11). This failure led to Patient #11 being restrained without specific orders in 4-point (bilateral wrists & bilateral ankles) restraints as well as a body net (a net restraint device used to secure a patient’s body to the bed). Northern Light Mayo Hospital’s policy titled, “Restraints,” last revised 09/20/2023 states in part, “...The order shall specify the method of restraint to be used...” Patient #11’s medical record revealed an order for violent restraints, which was electronically signed by Physician Assistant #1 on 11/12/2024 at 1:30 PM. Physician Assistant #1’s order stated in part, “...Injury to self, Soft limb, Order valid for 4 hours. Evaluate patient and order Restraint Continue Violent if indicated...” Physician Assistant #1’s order did not specify which limbs were to be restrained. On 04/30/2025 at 12:50 PM, the Quality Program Coordinator reviewed Patient #11’s medical record and confirmed that Physician Assistant #1 ordered, “soft limb” restraints for Patient #11, but did not specify which limbs were to be restrained in the order. The Quality Program Coordinator confirmed that per Patient #11’s medical record, the patient was placed in a body net and 4-point [hook-and-loop fastener] ankle and wrist restraints on 11/12/2024 at 1:45 PM. The Quality Program Coordinator additionally confirmed the body net was never ordered.”

“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: 47175 Based on observation and interview, the facility failed to ensure that meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for construction type and supporting construction for health care and/or other building occupancies. A 2-hour separation was not provided in accordance with section 8.2.1.3 on all 4 floors which is a deficiency in the Nursing Facility. On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following: 1. Fire stopping was found missing or in need of repair in the following locations above ceiling: MH1008 MH1017g MH1014 MH1044 MH1056 The surveyors confirmed this finding with the engineering supervisor at the time of the observation.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 47175 Based on observation and interview, the facility failed to ensure that Access-Controlled Egress Door assemblies are installed in accordance with 7.2.1.6.2 of NFPA 101 2012 edition and that doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side. On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following: 1. Exit door MH000 is equipped with a push to exit button, but is not equipped with the required approach sensor to unlock the door from the egress side. The push to exit button is to be used as a failsafe in conjunction with the approach sensor. 2.On the exit door nearest the lobby side leaving the ED a thumbturn lock is installed. The surveyors confirmed this finding with the engineering supervisor at the time of the observation.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 47175 Based on observation, the facility failed to ensure that doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 of NFPA 101 2012 edition that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following: 1. Doors MH1020 and MH1038, self-closing doors, are prevented from closing by use of manually operated foot pegs. The surveyors confirmed this finding with the engineering supervisor at the time of the observation.”

“Ramps and Other Exits CFR(s): NFPA 101 Ramps and Other Exits Ramps, exit passageways, fire and slide escapes, alternating tread devices, and areas of refuge are in accordance with the provisions 7.2.5 through 7.2.12. 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10 This Standard is not met as evidenced by: 47175 Based on observation, the facility failed to ensure that Ramps, exit passageways, fire and slide escapes, alternating tread devices, and areas of refuge are in accordance with the provisions 7.2.5 through 7.2.12. 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10 of NFPA 101 2012 edition On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following: 1. In the basement east stair near the morgue, a ramp has been installed and the placement of the handrails has not been modified to meet the requirements of chapter 7 of NFPA 101 2012 edition. The surveyors confirmed this finding with the engineering supervisor at the time of the observation.”

“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: 39983 The facility failed to protect hazardous area fire barrier walls and ceiling, having 1-hour fire resistance rating in accordance with NFPA 101 2012 edition Section 19.3.5.9 and that Doors shall be self-closing or automatic-closing and permitted to have non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Findings: On 04/03/2024 between hours of 9:45 am and 1:00 pm. surveyors accompanied with Engineering Supervisor observed the following: 1. In the universal hazardous waste storage room MH008e a piece of wood was found covering a hole in the ceiling. 2. Rooms labeled MH1024 and MH1052 are being used as storage rooms and require self-closing doors. The Surveyors confirmed these findings with the Engineering Supervisor at the time of observation.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 47175 Based on observation, the facility failed to ensure that hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 2010 edition, Standard for the Installation of Sprinkler Systems. On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following: 1. Sprinkler system coverage does not extend to the K0351 area surrounding the CT trailer. The surveyors confirmed this finding with the engineering supervisor at the time of the observation.”

“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: 47175 Based on observation, the facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following: 1. The center sprinkler head in the cafeteria in the basement was missing the escutcheon plate. 2. Storage rooms MH1031 and MH027 items were found stored withing 18” of a sprinkler head. This was corrected during the survey. The surveyors confirmed this finding with the engineering supervisor at the time of the observation.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 47175 Based on observation, the facility failed to ensure that Fire doors assemblies are inspected and tested annually in accordance with NFPA 80 2010 edition, Standard for Fire Doors and Other Opening Protectives. On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following: 1. Fire door MH1035 is equipped with lower latches that were not functioning correctly and did not completely latch. The surveyors confirmed this finding with the engineering supervisor at the time of the observation.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 47175 Based on observation, the facility failed to ensure that Storage locations of oxygen cylinders are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following: 1. 13 e-tanks were found stored in a room equipped and designed for storage of 12 or less e-tanks. The surveyors confirmed this finding with the engineering supervisor at the time of the observation.”