Centracare Health System - Melrose Hospital

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 48583 Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure 2 of 2 negative pressure rooms (for airborne isolation- a room which had a ventilation system that generated a negative pressure to allow air flow into the isolation room, while preventing contaminated air from escaping the isolation room), (Rooms 11 and 13) were properly maintained and monitored. Findings include: On 7/16/24 at 10:55 a.m., a tour of the nursing unit was completed with director of nursing (DON). During the tour, patient rooms 11 and 13 were observed to have the capabilities of being converted to a negative pressure room. DON confirmed rooms 11 and 13 were the CAH’s negative pressure rooms. DON demonstrated the negative pressure in room 13 was activated by closing the door and setting negative pressure on a panel on the wall to the right of the door. The panel indicated room 13 was set for negative pressure and turned green. The panel had a white note attached to the top which read an alarm would sound after 30 seconds of interruption of negative pressure. After five minutes of room 13’s door being closed, DON opened the door. The panel flashed orange and returned to green indicating negative pressure was currently activated. One minute after room 13’s door remained open, no audible alarm sounded and the panel continued to indicate negative pressure was activated. DON confirmed maintenance was responsible for the routine checks and DON was unsure if she was activating the panel correctly. DON stated the rooms should be checked with maintenance. On 7/16/24 at 12:10 p.m., maintenance director (MD) and DON arrived on the nursing unit to test the negative pressure rooms 11 and 13. MD indicated the panels on the wall for rooms 11 and 13 had not been set for an audible alarm. Registered nurse (RN)-A who was present on the unit, stated the alarms had gone off in the past when negative pressure was interrupted. MD indicated when the negative pressure was interrupted, the panels should have turned orange and then red indicating the negative pressure had been interrupted. MD confirmed the panel for room 13 was not functioning as the panel only flashed orange and returned to green while the door remained opened. MD demonstrated the negative pressure in room 11 was activated by closing the door and selecting negative pressure on the panel on the wall to the left of the door. When room 11’s door was open, the panel turned orange indicating negative pressure was interrupted and stayed orange for 20 seconds. The panel then began to flash from green to orange while the door remained open. No audible alarm sounded as stated on the note on the panel. MD confirmed both negative pressure rooms were not functioning properly. MD and DON further confirmed staff would not have been alerted if negative pressure was interrupted as the panels were displaying incorrect information and no audible alarm sounded. MD stated he checked the alarms on a regular basis and would provide documentation of regular checks. During an interview on 7/16/24 at 1:33 p.m., DON indicated MD had placed testing documentation into an online reporting system however, only the past three days had saved. The negative pressure rooms had not been checked in the past three days. DON confirmed there was no documentation the negative pressure rooms had been checked on a regular basis. During an interview on 7/17/24 at 3:53 p.m., infection preventionist (IP) confirmed the CAH had negative pressure rooms and indicated if the negative pressure rooms were not functioning it would pose a risk to staff and other patients if a patient needed to utilize the negative pressure room. Facility policy titled Tuberculosis Exposure Control Plan revised 1/24, patient placement - In the hospital, direct admission to an (Airborne Infection Isolation Room) AIIR was preferred to reduce the risk of exposure to others. The door of the AIIR must remain closed except when entering or exiting. Prior to every entry to the AIIR, monitor the alarm device to ensure the light indicator was green. Do not enter the room in the light indicator was not green; contact maintenance to establish negative air pressure. Requested facility policy on negative pressure rooms. Received facility policy titled Airborne Infection Isolation Room (AIIR) - Negative Pressure Room however, status was pending and the policy had not yet been approved.”

“A Recertification Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on July 16, 2024. At the time of this survey, CentraCare Health System - Melrose Hospital - Alexandria Radiology Oncology Clinic was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 483.70(a), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. The CentraCare Health System - Melrose Hospital - Alexandria Radiology Oncology Clinic is located in the Douglas County Hospital and is 1 story building with no basement. The clinic was built in 1997 and was determined to be type I(442) construction. The clinic has 3 exam rooms and is considered as accessory use to the hospital to maintain an I occupancy. There is a one hour smoke barrier between the clinic and the hospital with 20 minute doors. The requirement at 42 CFR, Subpart 482.41(B), is NOT MET as evidenced by:”

“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: 34764 Based on observation and staff interview, the facility failed to install the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.5.1, 19.3.5.4, and 9.7.1.1, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, sections 8.15.5.3. These deficient findings could have a isolated impact on the residents within the facility. Findings include: On 07/16/2024 at 1:15 PM, it was revealed by observation that there are no fire sprinklers installed in the parts room and in the storage room next to the parts room does not have adequate coverage for the high ceiling side of the storage room. An interview with the Regional Director of Radiology and the Clinic Manager verified these deficient findings at the time of discovery.”