Harbor Beach Community Hospital

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 38269 Based on observation, interview, and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), 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, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include: See tag: C-0912 - Failure to maintain physical plant space C-0930 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code C-0914 - Failure to maintain patient-care equipment”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 50585 Based on observation and record review, the facility failed to remove outdated vacutainer blood collection tubes according the facility’s policy from 1 of 1 supply carts resulting in the potential for less-than-optimal outcomes for three patients present in the facility. Findings include: On 11/13/2024 at 1140, six vacutainer blood collection tubes in the top drawer of the facility’s hyperthermia cart were observed to be expired. Three green vacutainer blood collection tubes had an expiration date of 9/30/2024 and three blue vacutainer blood collection tubes had an expiration date of 8/31/2024. Director of Operating Room Services Staff V confirmed the findings at the time of discovery. According to the facility’s policy “Supplies Inventory and Outdates,” dated 6/2024, the policy revealed that “On the 25th of each month the Midnight Shift Certified Nursing Assistant will check all supplies for the expiration dates” and “Any items that are outdated will be removed from inventory and a requisition will be placed with Materials Management.””

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 48030 Based on observation and interview, the facility failed to ensure Emergency Medical Equipment was available for use, resulting in the possibility of adverse outcomes for all patients that present to the Emergency Department (ED). On 11/13/2024 at 1123 a tour of Room 1 in the ED was conducted with Staff L (ED RN) and revealed the Broslow Bag (Emergency Resuscitation Kit for pediatric patients) did not have the most current version of the Broslow Tape (the tape used to measure patient length which provides medication dosing and appropriate equipment sizes) is available for use. The Broslow Tape in the Kit was dated 2002(a) and the most current edition available is 2019. When queried if a current (2019) version of the Broslow Tape was available for use, Staff L revealed “this is the only one I am aware of”. On 11/13/2024 at 1130 during the tour of the ED Staff L was queried if the facility had a Precipitous Birth Kit available for use. Staff L revealed the kit could be found in the “Clean Supply Room” and directed surveyor to an unmarked room located near the ED. Upon entry into the supply room, the area was found to be in disarray and a cart located in the corner contained various obstetric supply kits. The Precipitous Birth Kit was found in sterile packaging dated 2003 with a cardboard box of teddy bears and the exhaust hose for an air purifying system was on top of the cart. On 11/14/2024 at 0935 an interview with the Director of Infection Control (Staff I) and a tour of the “Clean Supply Room” was conducted. Staff I revealed she had been notified about the infection and quality control concerns related to the supplies in the room and the facility is “going to have the kits re-sterilized and clean the area”.”

“CONSTRUCTION CFR(s): The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services. This Standard is not met as evidenced by: 43001 Based on observation, interview and record review, the facility failed to maintain the hospital building’s walls and flooring in various areas rendering these areas not cleanable, resulting in the possible spread of infectious agents to all patients in the facility. Findings include: 1. On 11/13/24 at 1100 peeling paint from the walls in linen storage room next to room 154 was observed. Staff D was asked why the paint was peeling and Staff D stated they were not aware of the peeling paint in the room. They also stated no ticket was submitted by staff for repair in the Spiceworks system. 2. On 11/13/24 at 1102 peeling paint and degraded plaster were observed behind the toilet in room 154’s bathroom. Staff D was asked if they knew of this and Staff D stated they were not aware. They stated that they replaced a valve in the plumbing for the toilet approximately 10 years ago and the plaster is now degrading from this repair. They also stated no ticket was submitted by staff for repair in the Spiceworks system. 3. On 11/13/24 at 1120 peeling paint and degraded plaster were observed behind the toilet in room 171’s bathroom. 4. On 11/13/24 at 1132 two 6 inch by 6 inch floor tiles were missing underneath the steam autoclave in the central supply cleaning room as well as 2 rags and a bucket under the plumbing supply lines for the autoclave were observed. Staff D was asked why the tiles were missing and why the rags and bucket were there and Staff D stated that the tile was missing for as long as they can remember and were not aware that the rags and bucket were there. 5. On 11/13/24 at 1232 it was observed that approximately two feet of baseboard was missing on the south wall of the laboratory. Staff D was asked why this baseboard was missing and they stated that it must have been missed after completing a renovation construction project along this wall.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 43001 Based on interview and record review, the hospital failed to provide a preventative maintence program for mechanical equipment in the hospital resulting in potential failure of this equipment that could result in bad outcomes for patients being treated at the hospital. Findings include: 1. On 11/13/24 records were requested for preventative maintenance that was performed on the air handling units and exhaust fan units serving the hospital and Plant Operations staff D could not provide these records. They stated that the hospital had a server change approximately a year ago and these records were lost. Staff D was asked why another program was not created. Staff D stated that they haven’t been able to create another one.”

“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: 38269 Based on observation, interview, and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), 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, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include: See following K tags from corresponding LSC survey: K-321 K-761 K-781 K-908 K-919 K-923”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to investigate a grievance according to the facility’s policy for 1 (P-1) of 20 patients reviewed, resulting in the loss of the patient’s right to resolution of a grievance, and the potential for less-than-optimal outcomes. Findings include: According to medical record, P-1 was discharged from the facility’s Emergency Department on 9/20/2023. On 9/21/2023 at 0930, P-1 called the facility to make a complaint. Director of Risk Management Staff E received the complaint and according to the facility’s “Patient Relations Communication Form/Grievance Form,” P-1 “states he is calling to complain about the ER physician. States seven times he has had panic attacks.” The form also revealed that P-1 “usually receives Xanax or an IV (intravenous).” P-1 “was here at 6:15 a.m.” P-1 stated “he has never felt so humiliated. He had to drive all the way to (another city).” According to the “patient/caller desired resolution” section of the Grievance Form, P-1 “never stated desired resolution.” According to the “actions taken to address complaint/concern” section of the Grievance Form: P-1 “was here in our ER around 6 am with Physician Staff H and came to our ER today around 3 p.m. with Physician Staff S. (Police Officer) from the (local police department) was called. (Police Officer) talked to the patient and stayed during the time P-1 was here.” According to the “Follow-up/problem resolution section of the Grievance Form:” “Due to the nature of P-1’s continued inappropriate and unacceptable behaviors in the Emergency Department will discuss issuing a no trespassing letter. The letter will state patient can only come to our hospital for an emergency.” According to the “Is patient satisfied with resolution?” section of the Grievance Form, the report revealed that the “no” box was checked (the patient was not satisfied with resolution) with the following information: “Phone call made to patient. Patient still upset with (facility). After discussion, a no trespassing letter was not sent due to nature of patient’s violent behavior and concern that patient would come after hospital staff after receiving letter.” According to the “Complaint/Concern” section of the Grievance Form: P-1’s concern was labeled as a “complaint” and the complaint was “Unsubstantiated.” On 11/14/2024 at 1020, Director of Risk Management Staff E was asked why the complaint was not handled as a grievance and Staff E said they believed it was a “complaint.” According to the facility’s policy “Patient Relations: Complaints, Grievances, and Appeals Process,” dated 3/2024, the policy revealed that a definition of a complaint was “A written or verbal concern from a patient, or patient’s designated representative about care and/or services provided by (the facility) that can be promptly resolved by informal means.” The definition of a grievance was “A formal written or verbal grievance that is filed by a patient or a patient’s designated representative when a patient issue cannot be resolved promptly by (the facility’s) staff.””

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50585 Based on observation and interview, the facility failed to store patient care equipment away from dirty equipment in 1 of 1 storage areas observed, resulting in the potential for transmitting infectious diseases to the three patients in the facility at the time of observation. Findings include: On 11/13/2024 at 1115, a patient sliding board was observed stored upright in a storage room with the head of the sliding board touching the dirty floor. A dirty mop head was observed at the head of the sliding board contacting both the sliding board and the dirty floor. The mop handle was leaning against the sliding board. Director of Nursing (DON) Staff C was queried if the storage room was a clean or dirty storage room and Staff C said “clean.” DON Staff C confirmed the findings at the time of discovery.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 48030 Based on observation and interview the facility failed to post EMTALA signs in the areas most likely to be noticed by all individuals that enter the emergency department (ED) via the ambulance entrance resulting in the potential for all patients that enter the facility through this entrance to be uninformed of their rights. Findings include: On 11/13/2024 at 1110 during a tour with the Director of Nursing (Staff C) of the ED ambulance entrance, it was observed that the facility failed to have EMTALA (Emergency Medical Treatment and Active Labor Act) signage notifying patients of their rights under EMTALA. Staff C was queried where EMTALA signs were posted in the ED. Staff C responded that EMTALA signage was posted in the main entrance waiting area of the facility. Staff C was then queried if EMTALA signage was posted in the ambulance entrance, which is also used as an after hour entrance for all patients presenting to the ED. Staff C stated the only area that she has ever had the EMTALA signage posted was in the front entrance area.”

“On November 13, 2024, a Life Safety Recertification Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs, Bureau of Survey and Certification. At the survey, Harbor Beach Community Hospital was found not in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.90(a), Life Safety from Fire and the applicable provisions of the 2012 Edition of the National Fire Protection Agency (NFPA) 101, Life Safety Code and the 2012 Edition of NFPA 99, Health Care Facilities Code. The facility is a single story building of type II(222) construction, built in 1958. The building is fully sprinklered and has supervised smoke detection in the corridors and spaces open to the corridors. The facility has 15 certified beds. At the time of the survey the census was 3.”

“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: 36613 Based on observation and interview, the facility failed to ensure hazardous areas are protected by a fire barrier doors that are self-closing or automatic-closing in accordance with 2012 NFPA 101 8.7.1.1 and 8.7.1.3. This deficient practice could affect 10 occupants in the event of a fire or smoke event. Findings Include: 1. On November 13, 2024 at approximately 11:10 AM observation revealed the linen storage room door across from the doctors lounge does not close and positively latch. 2. On November 13, 2024 at approximately 11:15 AM observation revealed the old nuclear medicine room has been converted into a storage space containing combustible cardboard boxes. The door to the new storage space is not self closing or automatic closing. 3. On November 13, 2024 at approximately 11:30 AM observation revealed the door to the soiled utility prewash space is not on a self closure or automatic closing device. These findings were confirmed through interview with the maintenance director at the time of 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: 36613 Based on record review and interview, the facility failed to inspect and test annually in accordance with NFPA 101, 19.7.6, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives 5.2, 5.2.3. This deficient practice could affect all occupants in the event of a fire emergency. Findings Include: On November 13, at approximately 2:45 PM record review revealed the facility annual swinging fire door documentation does not have inspection and test information for all the swinging type fire doors in the facility. The inspection form only denotes the cross corridor fire doors. This may lead to the other fire doors in the facility failing to function as designed when needed during a fire. These findings were confirmed through interview with the maintenance director at the time of record review.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 36613 Based on observation and interview, the facility failed to ensure portable space heating devices are prohibited, unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit as required by 19.7.8. This deficient practice could affect 8 occupants in the event of space heater related fire. Findings Include: On November 13, 2024 at approximately 11:50 AM observation revealed a portable space heater running on the file cabinet shelf in the physical therapy space. The space heater could not be verified to not exceed 212 degrees Fahrenheit. These findings were confirmed thorough interview with the maintenance director at the time of observation.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 36613 Based on record review and interview, the facility failed to ensure the gas and vacuum systems are inspected and tests and records are maintained as required by 5.1.14.2.3, 5.1.15, 5.2.14, 5.3.13 and 5.3.13.4 of NFPA 99. This deficient practice could affect all occupants in the event of a medgas and/or med vacuum failure. Findings Include: On November 13, 2024 at approximately 2:00 PM record review revealed the facility cannot produce documentation to verify med vacuum is inspected at least annually. On November 13, 2024 at approximately 2:00 PM record review revealed the facility cannot produce documentation to verify the internal oxygen facility components are inspected at least annually. These findings were confirmed through interview with the maintenance director at the time of record review.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99) This Standard is not met as evidenced by: 36613 Based on observation and interview the facility failed to provide electrical safety measures in accordance with NFPA 99. 6.4.4.1.2.1. This deficient practice could effect 20 occupants in the event circuit breakers are accessed and shut off to resident rooms. 1. On November 13, 2024 at approximately 11:40 AM observation revealed the electrical circuit breaker box across from the Room 154 is unsecured. This will potentially allow the breakers to be inadvertently shut off terminating the power to patient rooms and other vital equipment. 2. On November 13, 2024 at approximately 12:00 PM observation revealed the electrical circuit breaker box next to Emergency Room 2 labeled panel F and Panel EH are unsecured. This will potentially allow the breakers to be inadvertently shut off terminating the power to patient rooms and other vital equipment. These findings were confirmed through interview with the Maintenance director at the time of 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: 36613 Based on observation and interview, the facility failed to ensure storage of nonflammable gasses meet all requirements of 11.3.1 through 11.3.4 and 11.6.5 of NFPA 99. This deficient practice could affect 10 occupants in the event of an oxygen related fire, oxygen cylinder damage or misuse. Findings Include: On November 13, 2024 at approximately 11:00 AM observation revealed oxygen cylinders in the oxygen cylinder storage closet next to room 154 are mixed and not segregated between full and empty cylinders. Full and empty cylinders were located together in the same location and not designated full and empty by dedicated signage. These findings were confirmed through interview with the maintenance director at the time of observation.”