Glacial Ridge Hospital

“FIRE SAFETY An annual Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 03/06/2024. At the time of this survey, Glacial Ridge Hospital Building 01 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. Glacial Ridge Hospital is licensed as a Critical Access Hospital and is a 2 story building with a full basement. The building was constructed at 6 different times. The original building was constructed in 1943 and was determined to be of Type II(222) construction. There were additions to this building in 1954, 1974, and 2001 which were determined to be Type II(000). A 2-story ER/OR with a basement was constructed in 2009 and was determined to be of Type II(111) construction. In 2016, a 1 story patient care unit with a full basement was constructed and was determined to be of Type II(111). The facility was surveyed as one building. The building is protected by a complete fire sprinkler system. The facility has a fire alarm system with smoke detection that is monitored for automatic fire department notification. The facility has a capacity of 25 certified beds with a patient capacity of 12 at the time of the survey. The requirement at 42 CFR, Subpart 482.41(b) is NOT MET as evidenced by:”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 49715 Based on observation and staff interview, the facility failed to maintain an egress corridors per NFPA 101 (2012 edition), Life Safety Code, section 7.1.10.1. These deficient findings could have a patterened impact on the residents within the facility. Findings include: 1. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation that a wheeled patient bed was being stored in front of an egress door in the radiology area. 2. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation that a housekeeping cart was being stored in the lower level south stairwell. An interview with the Maintenance Director verified these deficient findings at the time of discovery.”

“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: 49715 Based on observation and staff interview, the facility failed to maintain 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 8.6.6.1, and 9.1.1.7. These deficient findings could have an isolated impact on the residents within the facility. Findings include: 1. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation that items being stored in the walk-in cooler in the kitchen area within 18 inches of the sprinkler head. 2. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation there were several different types of wires zip tied and in contact with the fire sprinkler piping and hangers in the large basement storage room and the IT closet in the same area. An interview with the Maintenance Director verified these deficient findings at the time of discovery.”

“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: 49715 Based on observation, review of available documentation, and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, sections 9.7.5, and 9.7.7, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.1.1.2, and 5.4.1. These deficient findings could have a widespread impact on the residents within the facility. Findings include: 1. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation and review of available documentation and staff interview that the facility was overdue to have the annual inspection of sprinkler system. The last annual inspection was conducted on 01/10/2023. 2. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation that several spare sprinkler heads were not securely stored within the fire sprinkler head cabinets in the south and north riser rooms. An interview with the Maintenance Director verified these deficient findings at the time of discovery.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 49715 Based on a review of available documentation and staff interview, the facility failed to conduct fire drills under varied times and conditions per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.1.6, and 4.7.4. These deficient findings could have a widespread impact on the residents within the facility. Findings include: 1. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by a review of available documentation that the facility was not varying the times of the fire drills throughout the year on each shift. 2. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by a review of available documentation that the facility did not conduct a fire drill during the 2nd quarter of 2023 for the second shift. An interview with the Maintenance Director verified these deficient findings at the time of discovery.”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 49715 Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the residents within the facility. Findings include: On 03/06/2024 between 09:00 AM and 1:15 PM, it was revealed by a review of available documentation that the NFPA 99 Risk Assessment had not been completed for this facility. An interview with the Maintenance Director verified this deficient finding at the time of discovery.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 49715 Based on a review of available documentation and staff interview, the facility failed to provide documentation showing electrical receptacle testing and maintenance per NFPA 99 Standards for Health Care Facilities 2012 edition, sections 6.3.4.1.1, and 6.3.4.2. This deficient findings could have a widespread impact on the residents within the facility. Findings include: On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by review of available documentation that the required hospital-grade receptacle testing and inspection documentation was not available at the time of the survey. An interview with the Maintenance Director verified these deficient findings at the time of discovery.”

“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: 34083 Based on observation, interview and document review, the critical access hospital (CAH) failed to complete daily checks of the Zoll X series defibrillator monitors (used to create an electrical charge to stop an abnormal heart rhythm) for 3 of 3 defibrillator monitors reviewed equipment and supplies. Findings include: On 3/5/24 at 12:41 p.m., the Zoll X series defibrillator monitor on the medical surgical floor located on top of the crash cart had a testing strip exposed from the monitor indicating the monitor had only been checked 2/26/24 at 11:53 p.m., 2/27/24 at 11:33 p.m., 3/3/24 at 1:14 a.m., and 3/3/24 at 11:23 a.m. No additional testing strips were located. On 3/6/24 at 9:56 a.m., registered nurse (RN)-I stated overnight nurses were responsible for charging and testing the Zoll X series defibrillator monitors. RN-I further stated a report would printed out after the test was completed and the checklist would then be signed off. RN-I stated the overnight charge nurse was responsible for ensuring all checks were done and the checklist was signed off. On 3/6/24 at 11:59 a.m., chief nursing officer (CNO) stated nursing staff received Zoll X series defibrillator monitor training during orientation, and nursing staff were responsible for checking the Zoll X series defibrillator monitors daily. CNO further stated the defibrillator checks were included on the nightly checklist, and the charge nurse was responsible for ensuring all nightly tasks were completed. CNO stated she was not aware Zoll X series defibrillator monitors were not being checked nightly. CNO further stated she did not monitor the checklists daily because she thought the charge nurse was doing it. CNO stated her expectations were nursing staff should be checking the Zoll X series defibrillator monitors daily to make sure it is plugged in, charging, and daily testing is completed. The Zoll X Series Defibrillator Monitor Advanced Operator’s Guide undated directed to ensure the readiness and optimum working condition of the X Series Advanced unit, you should perform the following inspections and tests daily or at each shift change. The facility policy Defibrillation review/revised date 7/18, lacked information about daily checks. 42587 Findings include: On 3/5/24 at 1:59 p.m., in the emergency room (ER) daily checklists for ER rooms were reviewed. The checklists included testing the defibrillators in each room. The checklists revealed the following: December 2023, no dates listed for (1, 2, 3, 4, 5, 7, 8, 10, 11, 13, 14, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 28, 29, 30). No defibrillator checks were completed. January 2024, no dates listed for (1, 2, 3, 4, 6, 8, 9, 11, 13, 14, 16, 20, 21, 22, 23, 24, 26, 27, 29, 30, 31). No defibrillator checks were completed. In addition, on 1/12/24, the “Test Defib (30 joules)” was listed but not completed for ER 2. February 2024, no dates listed for (1, 3, 4, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 28). No defibrillator checks were completed. In addition, on 2/2/24, the “Test Defib (30 joules)” was listed but not completed for ER 1 and on 2/5/24, no checks were completed for ER 1 and ER 2. March 2024, no dated listed for (1, 2, 3). No defibrillator checks were completed. On 3/5/24 at 1:59 p.m., nurse technician (NT)-A stated part of her duties were to complete the checklists for all the ER rooms daily, which would include testing the defibrillators in ER room 1 and ER room 2. NT-A verified the sheets were missing several dates for the past few months, and the defibrillator checks were not being completed daily. On 3/5/24 at 2:05 p.m., emergency room manager (ERM)-H reviewed the checklists and verified the checks for the defibrillators were not being completed on a daily basis. ERM-H stated there were several days missing for the past few months. ERM-H stated when the NT was not working, another ER staff should have completed the checks.”

“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: 47372 Based on observation, interview, and document review, the critical access hospital (CAH) failed to maintain secure access to various departments throughout the hospital including the therapy department, emergency department (ED), laboratory, inpatient unit, surgical department and operating room, and identify visitors, patients, and the public. This had the potential to affect all patients and staff. Findings include: Basement On 3/4/24 at 1:38 p.m., the outside public entrance to the therapy department was observed to be open and accessible to the public with a sign that indicated “doors open at 6:45 a.m.” From the public access doors, patients, visitors, and the public had access to a set of double doors, labeled H030, with a sign that indicated “authorized personnel only.” The doors had direct access into the basement and a stairwell to the 1st floor of the hospital. The maintenance manager (MM)-D stated the doors closed at 6:00 p.m. and a video camera was observed directly above the double doors. MM-D stated the video cameras were recording, but staff did not actively monitor the cameras on a 24 hour/7 days a week basis. On 3/5/24 at approximately 8:30 a.m., the therapy receptionist (TR)-A stated the doors from the public entrance outside led directly to the double doors that indicated “authorized personnel only.” TR-A acknowledged visitors, patients, or the public could walk through those doors and would have access to the hospital without every checking in at the registration desk with staff. On 3/5/24 at approximately 9:00 a.m., the therapy manager (TM)-E stated the public entrance doors to the therapy department open at 6:45 a.m. and close at 5:30 p.m., and patients, visitors, or the public would have access through the double doors labeled “authorized personnel.” When walking through the double doors and directly to the left, down a hallway, there was direct access to the maintenance department. The maintenance supply closet was propped open and inside were two saw blades, WD-40, glue, liquid ice machine cleaner, 18”, 12”, and 10” wrenches, various power drills, and various nails and screws. When exiting the maintenance supply closet and taking a direct left, then a right, and walking down the hallway, patients, visitors, and the public had access to a stairwell. TM-E stated a patient, visitor, or the public could access the 1st floor of the hospital, which included the inpatient units, the ED, and the laboratory and radiology department without staff supervisor or knowledge. 1st Floor Registration: On 3/6/24 at 9:30 a.m., the main entrance receptionist (R)-C stated visitors would register at the reception desk. R-C would then call the unit and verify if the patient or unit was expecting a visitor. The visitor was then directed towards the wing of the hospital without staff accompaniment. 1st Floor Emergency Department: On 3/4/24 at approximately 2:00 p.m., inside of the patient care area of the ED, were two double doors labeled 1019, and a sign indicating “authorized personal only.” Through the double doors was an elevator which accessed the 2nd floor operating room (OR) and the basement, which included therapy services and maintenance. On 3/5/24 at approximately 12:30 p.m., registered nurse (RN)-A stated patients within the ED would be able to walk through the double doors with the sign indicating “authorized personal only” without staff supervision or acknowledgement, and have access to the elevator to the 2nd floor which included the preoperative and post-operative unit and an unlocked operating suite with equipment and an unsupervised anesthesia machine. In addition, patients from the ED, using the same elevator, could access the basement, which included therapy and the maintenance department, without staff supervision or knowledge. 1st Floor Laboratory Department: On 3/4/24 at approximately 2:30 p.m., the laboratory entrance, accessible to patients, visitors, and the public from the main and ED entrance, had a badge access reader for staff to scan themselves in and out of the laboratory department. However, the badge access reader had a green indication light, which indicated the door remained open without the need to scan a staff badge. Through the laboratory entrance was direct access to the laboratory draw rooms and inside was laboratory supplies that included needles, vacuum tubes, tourniquets, etc. Directly adjacent from the draw rooms, a door leading to the main laboratory was accessible. The main laboratory door did not include a badge access reader nor a video camera to monitor access. On 3/5/24 at approximately 10:00 a.m., the laboratory and radiology receptionist (LRR)-D stated the laboratory doors remained open from 7:00 a.m. to 7:00 p.m. On 3/5/24 at approximately 12:00 p.m., the laboratory manager (LM)-F stated the main laboratory entrance remained unlocked from 7:00 a.m. to 7:00 p.m., and acknowledged patients, visitors, and the general public could walk through the main laboratory doors, into the three main draw rooms and grab laboratory supplies which included needles, vacuum tubes, tourniquets, etc. and the main laboratory, which contained unlocked flammable chemicals without staff knowledge. 1st Floor Inpatient Unit: On 3/4/24 at approximately 3:30 p.m., access from the inpatient floor to the obstetrical unit was divided by two double doors. A staff badge access read was not identified, however a video camera was recording and providing a live video stream to the nurse’s station. However, there was no one actively monitoring the video monitors at the nurse’s station. On 3/4/24 at approximately 4:00 p.m., registered nurse (RN)-B stated patients or visitors from the inpatient unit who wanted to walk through to the obstetrical unit would be able to without staff supervision or knowledge. RN-B acknowledged the video monitors on the unit streamed live video to the nurse’s station; however, staff were not always actively monitoring the video cameras. On 3/6/24 at 10:01 a.m., the health unit coordinator (HUC)-H stated all inpatients wore a white, blue, or red wristband. If a visitor checked in at the registration desk, they are not given any type of identification. HUC-C also stated when she or staff checked in a visitor for the first time, they would confirm with the patient the visitor was authorized, and staff would escort them to the patient’s room. However, after the visitor’s first encounter, staff did not check to see if the visitor was authorized to access a patient’s room and did not escort the visitor to the patient’s room. 2nd Floor Surgical Department: On 3/6/24 at 10:11 a.m., the surgical technician (ST)-J stated patients check in at the ER reception desk, and are given a white wristband. Visitors register in the ED, and visitors do not wear any type of identification or name badge once registered. ST-J stated visitors would go from the 1st floor ED to the 2nd floor surgical department unaccompanied by staff. On 3/6/24 at 4:34 p.m., the chief executive officer (CEO) stated all entrances to the hospital remain locked except for the doors accessible to the public from the main entrance to therapy, the 1st floor main entrance and the ED, which all have video cameras. The CEO acknowledged all video cameras at the main entrances and registration desks were not always actively monitored by staff. The CEO stated the main entrance from the basement level therapy department directly accessible to the double doors labeled “authorized personnel only” would have the potential for a patient, visitor, or the public to walk through those doors and access the hospital without staff knowledge. In addition, the CEO stated patients within the ED would be able to walk through the double doors with a sign indicating “authorized personal” without staff knowledge, and could gain access to the basement and 2nd floor surgical department without staff supervision or knowledge. The CEO stated he was aware the laboratory department main doors remained unlocked during business hours. The CEO stated visitors did need to check in at the registration desks located at the main entrances of each department throughout the hospital. However, the CEO did state once a visitor has been to the hospital more than once and staff recognized them, there was no system to document authorized or unauthorized visitors. The CEO went on to state repeat visitors were not escorted by staff to their destination. The CEO stated because staff were not identifying visitors when they registered, there was a potential they or others could gain access to unauthorized areas in the hospital. The facility policy Hospital Patient Visitor dated 1/1/24, directed Glacial Ridge Health System welcomes patient’s choice of visitors including but not limited to a spouse, domestic partner, another facility member, or friends. The policy further directed Glacial Ridge Health System reserves the right to ask any visitor to leave in the event they are disruptive or disrespectful to the comfort of the patient they are visiting, as well as staff and other patients and visitors. In addition, the policy directed patients may decide to withdraw or deny permission for having visitors at any time throughout their stay, and anyone found in unauthorized locations may be re-directed and/or asked to leave.”

“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: 34083 Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings include: Please refer to the Life Safety Code inspection tags: K0211, K0351, K0353, K0712, K0901 and K0914 for additional information.”

“RESPONSIBLE FOR MEDICAL DIRECTION CFR(s): This Standard is not met as evidenced by: 40943 Based on interview and document review, the critical access hospital (CAH) failed to report a change in the medical director to the State Agency (SA). Findings include: The facility Medical Staff Minutes dated 2/14/23 at 7:35 a.m., identified the approval of the election of physician (P)-A as Chief of Staff. On 3/4/24 at 1:53 p.m., the chief executive officer (CEO) stated the medical director was appointed by the medical staff during the medical staff meeting in February, 2024. On 3/4/24 at 2:18 p.m., health information management (HIM)-K provided the policy to inform the SA regarding changes to the medical director; however, was unable to speak on the process. HIM-K stated the person responsible was not in the office that day and she was unable to find any documentation that identified a notification to the SA had been completed. The facility Bylaws of the Medical Staff undated, identified officers shall be elected at the annual meeting of the Medical Staff, which was usually held in February. Only active medical staff members may vote. Nominations would be made from the floor by members of the active staff only. Election shall be by closed ballot or voice vote at the annual meeting of the Medical Staff. All officers serve a two-year term from their election date or until a successor was elected. Officers shall take office on the first of the month following their election. The facility policy Notification to Department of Health dated 9/26/05, identified the facility would notify the SA if there was a change in CEO or medical director.”

“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: 34083 Based on observation, interview, and document review, the critical access hospital (CAH) failed to properly clean 1 of 2 Nova Statstrip Glucose monitors reviewed for blood glucose monitoring of patients. On 3/4/24 at 4:45 p.m., licensed practical nurse (LPN)-A was observed in P31’s room. LPN-A applied gloves, removed alcohol wipes from a plastic bin, removed the Nova Statstrip Glucose monitor along with testing strips from a basket and placed on P31’s bedside table. LPN-A obtained P31’s blood glucose level, removed gloves and charted P31’s blood sugar results. LPN-A placed the Nova Statstrip Glucose monitor back into the basket. LPN-A was not observed to clean the Nova Statstrip Glucose monitor prior to leaving P31’s room. On 3/5/24 at 11:00 a.m., LPN-A was observed to sanitize her hand and bring the blue basket with the Nova Statstrip Glucose monitor into P31’s room. LPN-A set it on P31’s bedside table. LPN-A applied gloves, pulled out and turned on the Nova Statstrip Glucose monitor. LPN-A completed a glucose check on P31. LPN-A placed the Nova Statstrip Glucose monitor back into blue basket and charted P31’s blood glucose level. LPN-A sanitized her hands and left P31’s room. LPN-A was not observed to clean the Nova Statstrip Glucose monitor before leaving P31’s room. LPN-A entered the medication room, and placed blue basket onto counter. LPN-A took the Nova Statstrip Glucose monitor out of the basket, opened an alcohol wipe, wiped the front of the Nova Statstrip Glucose monitor, and placed the Nova Statstrip Glucose monitor back in the blue basket. On 3/5/24 at 2:06 p.m., LPN-A stated the Nova Statstrip Glucose monitors needed to be cleaned before docking (charging) them. LPN-A stated the Nova Statstrip Glucose monitors needed to be cleaned with an alcohol wipe between patients. LPN-A stated the facility policy was the Nova Statstrip Glucose monitors should be cleaned with alcohol wipes prior to docking them. On 3/5/24 at 2:10 p.m., registered nurse (RN)-F stated when nursing staff were finished using the Nova Statstrip Glucose monitors, the monitors needed to be cleaned with alcohol wipes between use. RN-F stated when all patients have had their blood glucose checked, nursing staff were to clean the Nova Statstrip Glucose monitors with Sani-wipes and wait until the monitor was dry to dock it. RN-F stated, “I have used an alcohol wipe also. I use the alcohol wipes more than the Sani-wipes.” On 3/6/24 at 11:18 a.m., laboratory manager (LM)-F stated nursing staff were to be cleaning the Nova Statstrip Glucose monitors with Dispatch hospital cleaner disinfectant towels with bleach between each patient use and before docking. LM-F further stated manufacture’s recommendations for the Dispatch hospital cleaner directed the surface would need to stay visibly wet for one minute and left to air dry. On 3/6/24 at 11:59 a.m., chief nursing officer (CNO) stated Nova Statstrip Glucose monitors should have been cleaned with Sani-cloths or an alcohol wipe. The CNO further stated Nova Statstrip Glucose monitors could be cleaned with bleach wipes, standard alcohol wipes, or a Sani-wipe. The CNO stated she was not aware of recommendations from the laboratory and what wipes should have been used. The CNO confirmed the recommended cleaning wipes from the laboratory were not in the medication room. The CNO stated her expectation were Nova Statstrip Glucose monitors were wiped down between each resident and before/after use. The CNO further stated nursing staff were expected to follow the cleaning guidelines for cleaning the Nova Statstrip Glucose monitors. The Nova Biomedical manufacture’s recommendations for customer information bulletin dated 12/4/12 directed all meter external surfaces should be cleaned and disinfected with a fresh Clorox Healthcare Bleach Germicidal Wipe. The facility policy Nova Glucose Meter Cleaning dated 5/23/18 directed the Nova Blood Glucose meter should be cleaned and disinfected after each use using a bleach wipe such as Clorox Healthcare Germicidal Wipe.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 34083 Based on interview and document review, the critical access hospital (CAH) failed to ensure policies and procedures in the nursing, laboratory, anesthesia, facility wide, and emergency department were reviewed annually. Findings include: Review of nursing policies and procedures revealed the following: NURSING -Admission, Care of Antepartum/Intrapartum/Post-Partum Patient, and Discharge reviewed/revised 1/21. -Admission of Patient to Hospital reviewed/revised 2/21. -Malignant Hypothermia reviewed/revised 2/09. -Health Care Directive/POLST Policy & Procedure reviewed/revised 6/20. -Nova Glucose Meter Cleaning effective 5/23/18. -Nova Statstrip POC Blood Glucose System reviewed/revised 7/18. -Policy Governing the Administration of Medications reviewed/revised 2/13. -Administration of Intramuscular Injection (Adult and Pediatric) reviewed/revised 1/20. LABORATORY -Novanet effective 5/30/18. ANESTHESIA -Do Not Resuscitate, or Allow Natural Death revised 9/22/15. FACILITY WIDE -Verbal and Telephone Orders reviewed/revised 1/10. On 3/6/24 at 11:59 a.m., chief nursing officer (CNO) confirmed the above findings, and stated she was aware policies and procedures were not up to date. The CNO further stated the facility had been working on the policies and procedures, but not all of them had been updated. The CNO stated the facility’s plan was to get the policies and procedures updated by the end of the year. The CNO stated expectations were for each department to review the policies and procedures, and update them as needed.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 34083 Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure nursing staff followed the policy for medication administration for 1 of 1 patients (P14) observed for medication administration. Findings include: On 3/4/24 at 4:15 p.m., registered nurse (RN)-B was observed to gather supplies to give P14’s medications. RN-B reconstituted Pantoprazole (used to treat reflux disease) 40 milligrams (mg) with 10 millimeters (ml) of normal saline (NS) to achieve an intravenous (IV) push medication with the final strength of 40 mg. RN-B scrubbed the top of the Pantoprazole vial, injected 10 millimeters (ml) of NS, let it sit, then drew the 10 ml of medication from the vial and administered to R14. On 3/5/24 at 10:14 a.m., RN-F was observed to gather supplies to give P14’s medications. RN-F reconstituted Pantoprazole 40 mg with 10 ml of NS to achieve an IV push medication with the final strength of 40 mg. RN-B scrubbed the top of the Pantoprazole vial, injected 10 ml of NS, let it sit, then drew the 10 ml of medication from the vial and administered to R14. On 3/5/24 at 2:10 p.m., RN-F stated it was the first time she had reconstituted Pantoprazole since she started working at the facility. RN-F further stated nurses reconstituted many medications. On 3/6/24 at 11:59 a.m., chief nursing officer (CNO) confirmed the above findings and stated reconstitute of medications on the medical surgical floor was usually only done for IV push medications. The CNO stated pharmacy was responsible for reconstituting medications during pharmacy hours, and nursing staff should only reconstitute medications when the pharmacy staff were not in the office (after hours), on weekends, or in an emergency. On 3/6/24 at 1:00 p.m., the pharmacist (P)-a confirmed the above findings, and stated nursing staff would reconstitute some powder medications. P-A stated most of the reconstituted medications were antibiotics, but did include some additional medications. P-A stated medications should be reconstituted in the pharmacy during normal pharmacy hours, and the reason nursing staff were reconstituting medication during pharmacy hours on the medical surgical floor was for convenience. P-A stated all reconstitution of medications should be completed by the pharmacy and the only time nursing staff should be reconstituting medications was if pharmacy was not available (after hours) or in an emergency. The facility policy Pharmacy Policies and Procedures reviewed/revised 2/24, directed the preparation of admixtures of medications is the responsibility of the pharmacist or the licensed nurse (when the pharmacist is not available). Admixtures are to be prepared only in a dedicated area.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 34083 Based on interview and document review, the critical access hospital (CAH) failed to collaborate and communicate with the Organ Procurement Organization (OPO) to ensure every patient’s death was being reviewed. Findings include: Review of the facility’s Death Summary Report date 3/1/23 to 11/30/23, the facility had 12 deaths. Review of the facility’s 2023 Tissue & Eye Donation Activity Report dated 12/31/23, the facility contacted the OPO for 15 facility deaths. On 3/5/24 at 3:33 p.m., chief nursing officer (CNO) confirmed the above findings and stated she received a quarterly and yearly report from the OPO. The CNO stated she reviewed the report and nothing else was done with the report. On 3/5/24 at 4:22 p.m., the CNO stated she looked through the report for the compliance rate and the timeliness. The CNO stated indicated she did not match the report with reported facility deaths. The CNO further stated she had not had any communication with the OPO regarding the report. The CNO stated the report was sent to her, the acute care manager and the emergency department manager. The CNO further stated there was no additional communication with other departments regarding the report. The CNO confirmed the lack of communication between the facility and the OPO. A policy on OPO was requested, but not provided.”

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 34083 Based on interview and document review, the critical access hospital (CAH) failed to develop an abuse policy and procedure for its Swing Bed Unit to include immediate (not to exceed 2 hours) notification to the State Agency (SA) for all alleged violations involving abuse, neglect, exploitation or mistreatment. This deficient practice had the potential to affect all current Swing Bed patients and all future Swing Bed patients receiving services by the CAH. Findings include: The facility policy Reporting Abuse to State Agencies and Other Entities/ Individuals reviewed 1/24, directed all alleged/suspected violations and all substantiated incidents of abuse would be promptly reported to appropriate SA, other entities or individuals as required by law. The policy further directed notices would be provided to the above agencies/individuals within 24 hours after the occurrence of the incident, or when the facility learned of the abuse. On 3/6/24 at 2:35 p.m., the director of nursing (DON) stated she expected staff to contact her or the chief executive officer (CEO) immediately when an allegation of abuse was reported. The DON confirmed the facility policy identified the facility had 24 hours to report an allegation of abuse to the SA. In addition, DON stated she was not aware a facility was expected to report all allegations of abuse immediately. On 3/6/24 at 3:00 p.m., the CEO stated he believed the facility had 24 hours to report allegations of abuse, and was not aware the facility was expected to report immediately.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 34083 Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure comprehensive patient-centered care plans with goals were developed for 5 of 5 patients (P1, P28, P29, P30, and P31) reviewed on the Swing Bed (SB) Unit. Findings include: P1’s electronic medical record (EMR) revealed an admission date of 3/1/24, with diagnoses which included back and hip pain, and lumbago with sciatica. P1’s care plan revised 3/4/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, Occupational Therapy (OT) general evaluation and Physical Therapy (PT) general evaluation. The care plan lacked any measurable goals to ensure patient-centered care was provided. P28’s EMR revealed an admission date of 1/5/24, with diagnoses which included pneumonia and atrial fibrillation. P28’s care plan revised 1/17/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, OT general evaluation and PT general evaluation. The care plan lacked any measurable goals to ensure patient-centered care was provided. P29’s EMR revealed an admission date of 1/18/24, with diagnoses which included right hip repair and displaced fracture of right femur. P29’s care plan revised 1/31/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, OT general evaluation and PT general evaluation. The care plan lacked any measurable goals to ensure patient-centered care was provided. P30’s EMR revealed an admission date of 2/21/24, with diagnoses which included chronic obstructive lung disorder (COPD) and alcohol dependence. P30’s care plan revised 3/4/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, OT general evaluation and PT general evaluation. The care plan lacked any measurable goals to ensure patient-centered care was provided. P31’s EMR revealed an admission date of 3/1/24, with diagnoses which included enterococcal bacteremia and cellulitis of the right lower limb. P31’s care plan revised 3/4/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, OT general evaluation, PT general evaluation and infection risk. The care plan lacked any measurable goals to ensure patient-centered care was provided. On 3/6/24 at 9:15 a.m., registered nurse (RN)-D confirmed the care plans for P1, P28, P29, P30 and P31 were not patient centered and lacked goals. RN-D stated the facility was aware the care plans “needed work.” On 3/6/24 at 12:45 p.m., the director of nursing (DON) confirmed the SB patient care plans were not patient centered and lacked goals. The facility policy Swing Bed Comprehensive Care Plan Policy and Procedure reviewed 1/24, directed an initial care plan would be developed for each swing bed patient that would include measurable objectives and timetables to meet a swing bed patient’s medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment.”