Granite County Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 44770 Based on interview, record review, and policy review, the facility failed to comply with the conditions of participation outlined in §489.24(a)(1)(i): The facility failed to provide an appropriate MSE (medical screening examination) by a qualified medical provider for 3 (#s 5, 11 and 17) failed to inform and document the risks and benefits of refusing an examination and treatment for 2 (#s 5 and 11) of 20 sampled patients who presented for emergency care. Findings Include: Review of a facility policy titled, Passport Emergency Room Services, dated 10/26/17, showed: “Policy: It is the policy of Granite County Medical Center, in compliance with the federal COBRA Law, that the hospital emergency room provide a Medical Screening Examination to all who present themselves at their facility to determine if the patient has an emergent condition.” Review of a facility policy titled, Emergency Transfer Protocol, dated 10/26/17, showed: “Policy: It is the policy of Granite County Medical Center to provide ‘emergency services and care’ within the capability of the facility and staff to any individual who requests services, examination, or treatment ... 5. Refusal of Treatment or Transfer: a. Should any patient who comes to the Medical Center seeking emergency treatment refuse further medical examination and treatment or refuse a transfer to another medical facility, he or she (or a person acting on the patient’s behalf) shall be informed of the risks and benefits to the patient ...” -Patient #5 presented to the facility seeking medical care on 12/24/23. The facility did not provide a MSE for patient #5 and did not require signed documentation by his guardian showing she had been informed of the risks and benefits of leaving the hospital prior to receiving a MSE by a qualified medical provider. (Refer to 2406) -Patient #11 presented to the facility seeking medical care on 4/2/24. The facility did not provide a MSE for patient #11 and did not require signed documentation showing she had been informed of the risks and benefits of leaving the hospital prior to receiving a medical screening evaluation by a qualified medical provider. (Refer to 2406) -Patient #17 presented to the facility on 5/13/24 with complaints of pain between her shoulder blades that made it hard for her to breath. In triage, the patient had an elevated blood pressure and low blood oxygen saturation of 88% (normal is greater than 92%). Pain medication and a muscle relaxer was administered to the patient with some improvement. However, the patient continued to have pain at discharge, and the MSE did not include further evaluation of the patient’s ongoing pain, along with the presenting low blood oxygen level and high blood pressure, to determine whether the patient was experiencing an emergency medical condition. (Refer to 2406)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44770 Based on interview and record review the facility failed to provide an appropriate MSE (Medical Screening Examination) for 3 patients (#s 5, 11, and 17) and failed to obtain signed AMA (Against Medical Advice) forms including explanation of risks of leaving the hospital AMA for 2 (#s 5 and 11) of 20 sampled patients who presented for emergency care. Findings include: 1) Record review of patient #5’s electronic medical showed, patient #5 presented to the facility on 12/24/23 seeking care for upper respiratory illness and requesting testing for COVID. There was no evidence within the medical record that a qualified medical provider examined patient #5 on 12/24/23 to determine if an emergency medical condition existed. The electronic medical record lacked a signed AMA form explaining the risks of leaving the hospital AMA. During an interview on 6/13/24 at 11:36 a.m. staff member I stated he was the nurse working when patient #5 came to the ED (Emergency Department) on 12/24/23. Staff member I said the patient’s mother called prior to arrival asking for a COVID test for the patient and said she told him the patient was having symptoms of an upper respiratory infection. Staff member I said he phoned the provider, and the provider told him to order the COVID test and call her when the patient arrived. Staff member I said he obtained the specimen and sent it to the laboratory for analysis. When the results were complete, he told the mother the test was negative and then called the provider. Staff member I stated the mother told him the COVID test was all she wanted and left with the patient before the provider could arrive. Staff member I said he usually would get an AMA form and have the patient or guardian sign it. He said he was not sure why there was not one in the chart. He stated, “they must not have scanned it into the medical record.” Staff member I said, “I should have made a note or something showing I talked to her about the risks of leaving AMA, but I don’t think I did that.” During an interview on 6/6/24 at 11:41 a.m., staff member H said the normal procedure to follow when a patient presented to the ED would be for the nurse to take the patient back to the ED and get the triage information. Then, they should call the provider if they aren’t already in the facility, to come see the patient. She said usually she would assess the patient before she ordered any tests, but in this case on 12/24/23 with patient #5, the nurse called and asked if he could order the COVID test for the patient. She told him that would be ok, but to call her when the patient arrived at the facility. She said the nurse did not call until the test result was back, and then he called her to say the mother of the patient had already left with the patient. Staff member H said she did not get an opportunity to provide an MSE for patient #5 because the patient was gone before she could arrive at the facility. 2) Record review of patient #11’s electronic medical record showed patient #11 presented to the facility on 4/2/24 seeking care for severe pain. There was no evidence within the electronic medical record that a qualified medical provider examined patient #11 to determine if an emergency medical condition existed. The electronic medical record lacked a signed AMA form explaining the risks of leaving the hospital AMA. The nurse’s note showed the patient “did not want to wait for an ambulance ride.” During an interview on 6/5/24 at 5:30 p.m., staff member B said the nurse who wrote the note in patient #11’s chart was not available for interview. Staff member B said she was unsure what the nurse meant when she wrote the patient did not want to wait for an ambulance and left before she was seen by the provider. Staff member B said there was no AMA form available for patient #11 for the ED visit on 4/2/24. 3) Review of patient #17’s electronic medical record showed the patient arrived at the facility on 5/13/24 seeking emergency medical care for back pain between her shoulder blades that made it hard for her to breath. Patient #17’s vital signs taken in triage were significant for high blood pressure and a low blood oxygen level of 88% (normal value is greater than 92%). The provider’s documentation showed the patient, who had a history of multiple myeloma diagnosed on 9/26/23, and a history of heart valve replacement, presented with reports of a four-day onset of mild back pain that suddenly became severe while lying in bed the previous night. The pain was reported as constant and was not relieved by over-the-counter medication or changing positions. “Patient reports never having pain like this before. It hurts to move and take a deep breath. Feels sharp and stabbing.” The provider notes showed the patient had tachypneic breathing (fast breathing), “grunting in pain with any movement or deep breathing...obvious pain with most actions...any quick breaths or movement causes her to cry out in pain.” The patient complained of tenderness to palpation on both sides of her back below her shoulder blades, however, the provider notes failed to show documentation of physical examination of patient #17’s spine, neurological examination of patient #17’s lower extremities, and did not include patient #17’s bowel and bladder continence (important for assessing emergency conditions related to the spine causing back pain). The provider ordered intravenous (IV - in the vein) fentanyl (narcotic medication used for severe pain) for the patient, and noted that it provided “no relief.” Nurse documentation showed that eight minutes after the IV fentanyl administration, the patient reported her back pain had not decreased, she was holding her breath and not breathing normal due to the pain. Patient #17 was then administered IV hydromorphone (opioid medication for moderate to severe pain) as ordered by the provider, and 19 minutes later, the patient reported that her pain was improved “as long as I don’t move.” Nursing documentation showed that a third medication, orphenadrine (muscle relaxant) was ordered by the provider and administered IV, and the patient was immediately assessed as “much more relaxed.” The provider documented that the patient was feeling a “little better,” but continued to have spasms with movement. The provider discharged the patient home with a diagnosis of “rhomboid (muscles located between the shoulder blades) spasm.” However, during the patient’s discharge, the nurse noted that when the patient was placed in a wheelchair, “she was in pain again.” The nurse notified the provider, then proceeded to discharge the patient with instructions to take the prescribed pain medication (Hydrocodone-acetaminophen) and muscle relaxer (Robaxin) at home. The provider notes did not include a list of differential diagnoses that were considered, evaluation with a chest CT (computerized tomography, a type of imaging that provides a high level of detail of the organs and structures inside the body) for possible aortic dissection (tear in the body’s main artery) or pulmonary embolism (blockage of an artery in the lung), which can be associated with the patient’s presenting signs and symptoms, or a clear source for the patient’s pain, shortness of breath, hypoxia, and hypertension. Review of patient #17’s electronic medical record from another facility showed, patient #17 arrived at their facility on 5/16/24 seeking emergency medical care for continuing pain in her back. Patient #17 underwent a CT of her chest, abdomen, and pelvis. She also had additional laboratory testing. The provider notes showed “ ... CT scan however showed multiple myeloma at multiple levels in her thoracic spine as well as in her bilateral femurs. In particular there is a lesion at T6 which causes spinal canal stenosis and I suspect this is the culprit for the patient’s pain.” Patient #17 was treated with intravenous pain medication and was referred to her multiple myeloma specialist. During an interview on 6/6/24 at 10:46 a.m., staff member E stated she remembered patient #17. She stated her initial concern was ruling out a cardiac event that could be causing the patients symptoms. She stated, based on her lack of injury and her history of having back pain she decided an x-ray of her spine was not necessary. Staff member E said, “I suppose since she is 82 there could have been a pathologic fracture of the spine but usually there would be pinpoint tenderness or a certain movement that caused the pain. She also had multiple myeloma so possibly she could have had mets (metastasis) to the spine.” She said she did not remember if she had a conversation with the patient or her family about admitting her to the facility for pain control but that she knew patient #17 was still in pain when she was discharged and felt that the pain was to be expected with the movement of putting her in the wheelchair and then into the car. Staff member E said she felt patient #17 would do fine at home with the medications she was discharged with once she was home and lying still. Staff member E did not communicate a concern for aortic dissection or pulmonary embolism for patient #17. During an interview on 6/6/24 at 12:58 p.m., staff member J said she was the nurse who took care of patient #17 on 5/13/24. She said patient #17 was in pain but after she gave the patient intravenous pain medication, she became more comfortable. She said patient #17’s daughter asked her if they would admit her for pain control. She told her she did not think they would, but she informed staff member E patient #17 was still in pain when she got her up into the wheelchair to discharge her. Staff member J said Staff member E told her to tell the family to give patient #17 the medications provided as soon as they arrived home and that patient #17’s pain should improve once she was home. During an interview on 6/18/24 at 8:29 a.m. NF2 said she took patient #17 to the facility on 5/13/24 because she was having severe back pain. She said she spoke to the nurse about admitting her to the hospital to control her pain and was told they would not admit her. She said, “I took her home because they clearly were not going to admit her. I couldn’t believe they didn’t even do an x-ray of her spine. We ended up taking her to [other hospital name] three days later.” NF2 said the imaging showed she had multiple myeloma in her spine that was causing her pain. NF2 said patient #17 was treated with radiation but she did not handle the radiation well and died 2 weeks later. Review of a facility policy titled, Passport Emergency Room Services, dated 10/26/17, showed: “Policy: It is the policy of Granite County Medical Center, in compliance with the federal COBRA Law, that the hospital emergency room provide a Medical Screening Examination to all who present themselves at their facility to determine if the patient has an emergent condition.” Review of a facility policy titled, Emergency Transfer Protocol, dated 10/26/17, showed: “Policy: It is the policy of Granite County Medical Center to provide ‘emergency services and care’ within the capability of the facility and staff to any individual who requests services, examination, or treatment ... 5. Refusal of Treatment or Transfer: a. Should any patient who comes to the Medical Center seeking emergency treatment refuse further medical examination and treatment or refuse a transfer to another medical facility, he or she (or a person acting on the patient’s behalf) shall be informed of the risks and benefits to the patient ...””

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 32381 Based on record review the facility failed to plan and implement a provision of subsistence needs for the staff and the residents. This affects all occupants in the facility. Findings include: 1. Review of the EP plan, policies, and procedures on 4/15/24, reflected the facility’s emergency plan lacked policies and procedures for subsistence needs for staff and residents, particularly specific policies describing alternate sources of energy to maintain proper temperatures, emergency lighting, and for the life safety systems such as sprinkler, fire alarm, and smoke detection.”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 32381 Based on record review, the facility failed to develop policies and procedures related to the emergency and standby power systems for the EP plan. The record review showed insufficient information about the role of the emergency generator meeting care needs of the patients, the other occupants, as well as the building’s needs based on the facility’s safety and hazard vulnerability assessment. This deficiency affects all of the occupants in the facility. Findings Include: 1. Review of the EP plan on 4/15/24 reflected a lack of specific details about the emergency generator and what kind of services could be supported by the onsite emergency generator, i.e., the building temperatures, daily kitchen functions, safe food storage, illumination of the exit halls and exit signs, and the fire alarm, extinguishing and detection systems in the building.”

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code (LSC) recertification survey was performed on 4/15/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies of NFPA 101. Facilities surveyed under the hospital provider number were as follows: BD Old Hospital 01 Bed Addition The building construction type was found to be Type II (111) and contained 5 smoke compartments (4 main level and 1 basement). A new CT room addition has been added since the last survey of the facility on 4/25/17. There is a two hour separation between the former long term care (now swing beds) and the remaining CAH for this facility. The facility had 17 patients/residents at the time of survey. These requirements were not met as evidenced by the following deficiencies:”

“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: 32381 Based on observation, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5.10.2. Findings include: 1. During an observation on 4/15/24 at 3:15 p.m., the basement storage room was inspected. The corridor door was found to have a two-step locking mechanism installed, meaning, it was fitted with a lock which required more than one motion to open the doors. The room had the capacity to hold three or more people. 2. During an observation on 4/15/24 at 3:17 p.m., the central supply room in the basement was inspected. The corridor door was found to have a two-step locking mechanism installed, meaning, it was fitted with a lock which required more than one motion to open the doors. The room had the capacity to hold three or more people. 3. During an observation on 4/15/24 at 3:20 p.m., the laundry room was inspected. The corridor door was found to have a two-step locking mechanism installed, meaning, it was fitted with a lock which required more than one motion to open the doors. The room had the capacity to hold three or more people.”

“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: 32381 Based on observation, the facility failed to ensure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. Findings include: 1. During an observation on 4/15/24 at 2:40 p.m., the soiled utility room on the LTC side was inspected. It is considered a hazardous area. The corridor door to the room failed to close and latch under the power of the self-closer.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8). Findings include: 1. During an observation on 4/15/24 at 2:23 p.m., the south hall corridor was inspected. There was an ABHR station mounted over an outlet in the hall, just outside the supply room.”

“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: 32381 Based on observations, the facility did not have fire suppression sprinklers under the basement crawl area per NFPA 101, 2012 Edition, Section 19.1.6.1 and Table 19.1.6.1. Findings include: 1. After review of previous survey reports and a discussion with the maintenance supervisor on 4/15/24, the crawl space under the South Wing of the original hospital building was observed on 4/15/24 and it is not sprinklered as required by NFPA 101 for Type V (111) construction. This crawl space is viewed as a concealed combustible space since the wood floor joists and wood deck are exposed. Although sprinkler mains run through this crawl space, sprinkler heads were not installed.”

“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: 32381 Based on observation, interview, and record review the facility failed to: a) complete a 5-year internal inspection of the sprinkler piping in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 14.2.1., b) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2. Findings include: 1. A review of facility records was unable to determine when or if the 5-year internal inspection of the sprinkler system had been completed in the last five years. There was nothing noted on the sprinkler reports nor was there any information of such on the standpipe. In an interview on 4/23/24 at 10:50 a.m., staff member A stated the vendor was looking for it and had not located the information as of that time. 2. During an observation on 4/15/24 at 3:30 p.m., the boiler room was inspected. There was a large vent pipe for the gas-fired water heater which was found to be supported off the over-head sprinkler pipes. There was also copper piping for the water heater found to be supported from the over-head sprinkler pipes. 3. During an observation on 4/15/24 at 3:35 p.m., the maintenance office was inspected. There was an electrical conduit going to a ceiling mounted light in the room which was taped to a sprinkler pipe in the room.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure doors were resistant to the passage of smoke in accordance with NFPA 101, 2012 Edition, Sections 19.3.6.3.1. Findings include: 1. During an observation on 4/15/24 at 3:20 p.m., the basement laundry door was inspected. The door was found to have a large gap on the lower half of the door on the latch side of the door. It was too large to be resistant to the passage of smoke.”

“Corridor - Openings CFR(s): NFPA 101 Corridor - Openings Transfer grilles are not used in corridor walls or doors. Auxiliary spaces that do not contain flammable or combustible materials are permitted to have louvers or be undercut. In other than smoke compartments containing patient sleeping rooms, miscellaneous openings are permitted in vision panels or doors, provided the openings per room do not exceed 20 square inches and are at or below half the distance from floor to ceiling. In sprinklered rooms, the openings per room do not exceed 80 square inches. Vision panels in corridor walls or doors shall be fixed window assemblies in approved frames. (In fully sprinklered smoke compartments, there are no restrictions in the area and fire resistance of glass and frames.) 18.3.6.5.1, 19.3.6.5.2, 8.3 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to maintain corridor doors without openings or transfer grilles in accordance with NFPA 101, 2012 Edition, Section 19.3.6.4.1. Findings include: 1. During an observation on 4/15/24 at 2:47 p.m., the acute side corridor was inspected. There were transfer grilles in corridor doors in the IT room, the biohazard room, and the “empty” oxygen storage room. Only bathrooms and janitors closets may have transfer grilles in corridor doors.”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure the resident smoking area was confined to a safe area, in accordance with NFPA 101, 2012 Edition, Section 19.7.4.(5). Findings include: 1. During an observation on 4/15/24 at 2:11 p.m., the smoking courtyard was inspected. Along the side of the building away from the courtyard, there was an area which staff used to smoke. There was no metal can with a self-closing lid. There was however, two other large garbage cans with regular trash inside, one of which had cigarette butts thrown in. In the courtyard was another garbage can which was not self-closing, in which more cigarette butts were thrown in. There was a smoking resident being supervised in another part of the courtyard in an area which lacked any portable extinguisher, and a metal can with a self-closing lid, along with another plastic garbage can with trash and more cigarette butts discarded inside. The facility failed to provide any facility-wide smoking policy which was requested upon exit.”

“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: 32381 Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). Findings include: 1. Review of the fire safety maintenance records on 4/15/24., reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.”

“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: 32381 Based on observation and interview, the facility failed to utilize portable space heaters in a health care occupancy in accordance with NFPA 101, 2012 Edition, Section 19.7.8. Findings Include: 1. During an observation on 4/15/24 at 2:35 p.m., resident room 11 was inspected. There was a portable space heater in use in the room. Portable space heaters are not allowed in resident rooms.”

“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: 32381 Based on interview and record review, the facility failed to complete annual receptacle testing of non-hospital grade receptacles in patient care areas. Findings include: During an interview on 4/15/24 at 12:30 p.m., staff member A stated he had not completed the receptacle retention testing. He had the tool for it, but it was not done. Record review on 4/15/24 revealed non-hospital grade receptacles located in patient care rooms in the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition. Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).”

“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: 32381 Based on observation, the facility failed to ensure that the oxygen storage locations were maintained, and oxygen was stored in accordance with NFPA 99-2012 Edition, Sections 11.3.4.1, 11.3.4.2, 11.3.2.3, and 11.3.3. Findings include: 1. During an observation on 4/15/24 at 2:20 p.m., the oxygen storage area was observed. The oxygen storage area was located in the south hall supply and equipment room and it lacked a cautionary oxygen sign. The sign must include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING There was also several combustible slings hung above the oxygen rack and were hanging down and resting on top of the oxygen tanks. 2. During an observation on 4/15/24 at 2:25 p.m., while inspecting the patient rooms, it was found the facility was found to be storing large K-sized oxygen tanks in rooms 3, 9 and 10. This is not allowed as only 300 cubic feet of oxygen is allowed to be stored outside the oxygen storage room. Each K tank holds 250 cubic feet of oxygen.”

“CLINICAL RECORDS CFR(s): §485.638 Condition of Participation: Clinical Records This Condition is not met as evidenced by: 45448 Based on the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Clinical Records. Based on interview and record review, the facility: - failed to have a process in place to verify the completeness of medical records; - failed to ensure all patient records contained a properly executed informed consent for care; and - failed to ensure a medical doctor co-signed and assumed full responsibility for the history and physical when a patient was admitted to the facility by a mid-level provider.”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 44769 Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Program. Based on interview and record review the facility failed to communicate antibiotic stewardship to facility staff (See C 1242); the facility failed to develop and implement an antibiotic stewardship program (See C 1244); and the facility failed to document antibiotic stewardship activities (See C 1246).”

“DRUG AND BIOLOGICALS CFR(s): Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. This Standard is not met as evidenced by: 45448 Based on observation and interview, the facility failed to implement a process for ensuring expired medications were removed from use in the emergency department. This deficient practice had the potential to affect all patients requiring medication in an emergency. Findings include: During an observation on 4/8/24 at 1:15 p.m., the emergency treatment room was observed to have the following expired medications: Narcan Nasal Spray 4mg; expiration February 2024, 2 applicators, and November 2023, one applicator Heparin 5000u; expiration 3/1/24, 6 vials Enalaprilat 1.25mg: 3/2024, 5 vials During an interview on 4/8/24 at 2:10 p.m., staff member B said nursing staff were responsible for checking all medication for outdates and the central supply staff were responsible for checking all supplies for outdates. Staff member B said outdates were checked once a month and replaced. During an interview on 4/9/24 at 10:12 a.m., staff member A said there was an expectation that medication be checked by staff and replaced prior to the expiration date.”

“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: 44769 Based on interview and record review, the facility failed to account for acquisition and disposition of controlled medications. This deficient practice had the potential for controlled medication diversion. Findings include: During an interview on 4/8/24 at 2:00 p.m., NF1 stated she had been meeting with staff member A on a weekly basis, working on a process for accounting for wasted and expired controlled medications. During an interview on 4/9/24 at 8:50 a.m., staff member A stated there is not a process for accounting for wasted controlled medications and that he had been meeting with NF1 to come up with a process. Staff member Abstated that he did not know who comes and empties the wasted controlled medications lock box at the facility. A review of a facility policy, with a revision date of 8/22/2022, titled, “Medication Storage, Labeling and Disposal,” showed: “DISPOSAL [Facility Name] is responsible for the disposal of medications in its possession. ... All controlled substances will be counted and signed by two licensed nurses listed and taken and dispensed into disposal bin that is provided by the pharmacy. All substances will be documented by amount. ... the facility will maintain a list of all Narcotics and non-narcotic med disposal. ...””

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to provide a nutritional assessment for an acute swing bed admission, following surgical repair of a fractured femur, for 1 (#4) of 20 sampled patients. This deficient practice has the potential to affect patients to obtain their highest level for healing. Findings include: During and interview on 4/9/24 at 7:32 a.m., patient #4 said he had been transferred to the facility for physical therapy, following a surgery to repair his femur fracture. Patient #4 said he did not remember talking to anyone about his nutritional needs for healing, following his surgery. Patient #4 said he spoke with a staff member about his food preferences shortly after arriving at the facility. During a telephone interview on 4/10/24 at 10:12 a.m., staff member R said he visits the facility once monthly and provides dietary evaluations to one third of the patients. Staff member R stated he would evaluate any new patients and provide quarterly evaluations on patients residing in the facility long-term. Staff member R said the dietary manager would approach any new patients and ask about preferences, allergies, and any special dietary requests. Staff member R said the dietary manager would then notify him of the preferences, and they would have a conversation on the patients needs and his recommendations. Staff member R said he would then see the patient and provide an evaluation if the patient was still admitted to the facility. Staff member R said he did not routinely make a note in the EMR of any discussion with the dietary manager regarding the patients. Staff member R said there was not a way to track patients needing to have evaluations in the current EMR. Staff member R stated he has his own system of tracking patients for their quarterly evaluations. Staff member R said he would document his assessments in the facility EMR and would note the date they had been evaluated in his records. Staff member R stated his documentation was not in the EMR; he did not have a way to recover the information, and he does not have a separate note for his evaluations. Staff member R said he did not have a record of seeing patient #4 and was not aware he was admitted following a surgical repair of his femur. Record review of patient #4’s electronic medical record, with an admission date of 3/28/24, did not contain a nutritional assessment. Record review of a facility policy, “Initial Patient Nutritional Screening,” with a revision date of 12/8/2018, showed: “ ...4. The Registered Dietitian will evaluate each new Patient in the facility and complete an assessment. ...””

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to have a process in place to verify the completeness of medical records for 13 (#s 2, 3, 4, 6, 7, 8, 9, 10, 11, 13, 17, 18, and 20 ) of 20 sampled residents. This deficient practice had the potential to affect all medical records for patients receiving care at the facility. Findings include: A review of patient #2’s EMR, with an admission date of 3/14/23, failed to contain a social services evaluation, or a history and physical. A review of patient #3’s EMR, with an admission date of 4/2/24, failed to contain a signed copy of the patient rights, and include notification of visitation rights. A review of patient #4’s EMR, with an admission date of 3/28/24, failed to contain a signed copy of the patient rights, grievance information, informed consent to treat, notification of advanced directives, notification of visitation rights, a care plan, and a nutritional assessment. A review of patient #6’s EMR, with an admission date of 1/19/21, failed to contain an informed consent to treat, grievance information, and notification of advance directives. A review of patient #7’s EMR, with an admission date of 3/1/24, failed to contain a signed copy of the patient rights, and include notification of visitation rights. A review of patient #8’s EMR, with an admission date of 1/30/24, failed to contain a signed copy of the patient rights, notification of visitation rights, and an informed consent to treat. A review of patient #9’s EMR, with an admission date of 8/4/23, failed to contain a signed copy of the patient rights, notification of visitation rights, and a care plan. A review of patient #10’s EMR, with an admission date of 5/12/20, failed to contain a signed copy of the patient rights, notification of visitation rights, grievance information, and a nutritional assessment. 44769 A review of patient #11’s EMR, with an admission date of 4/24/23, failed to contain a signed copy of grievance information. A review of patient #13’s EMR, with an admission date of 6/23/23, failed to contain a signed copy of patient rights and grievance information. A review of patient #17’s EMR, with an admission date of 10/19/23, failed to contain a signed copy of patient rights, grievance information, notification of visitation rights, and notification of advance directives. A review of patient #18’s EMR, with an admission date of 10/19/23, failed to contain a signed copy of patient rights, grievance information, notification of visitation rights, and notification of advance directives. A review of patient #20’ s EMR, with an admission date of 4/2/24, failed to contain a signed AMA form. During an interview on 4/9/24 at 3:11 p.m., staff member O said the facility had a breakdown in their electronic medical records and scanning of patient records into the system, and the documents disappear when the patient is discharged. Staff member O said the patients had to be discharged because the system would “bog” down and then the patient would need to be re-admitted. Staff member O siad some of the information from the previous admit would not be accessible, only the date the documentation was created showed in the system. Staff member O stated care plans had to be copied from one admission to the next; if it was not copied, it would not show in the system. Staff member O said chart reviews were completed by staff, but she was not aware of anyone checking the chart to make sure all items were contained within the EMR. During an interview on 4/10/24 at 10:07 a.m., staff member O stated patients are given rights and grievance forms, but the forms were not always signed by the patient. Record review of a facility policy, “Medical Record Content,” with a revision date of 10/31/2017, showed: “ ...1. The patient medical records for acute and swing bed patients are required to contain at least the following: ... c. Physical examination ... e. Evidence of appropriate informed consent f. Clinical observations, including clinical notes, consultation reports, nursing notes, and entries by specified personnel ...n. Social Services assessment o. Patient’s Rights ...q. Advanced Directives ... w. Admission Care Plan ...””

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to ensure all patient records contained a properly executed informed consent for care for 3 (#s 4, 6, and 8) of 20 sampled patients. This deficient practice had the potential to affect all patient choices when consenting for care in the facility. Findings include: A review of patient #4’s EMR, with an admission date of 3/28/24, failed to contain a signed informed consent to treat. A review of patient #6’s EMR, with an admission date of 1/19/21, failed to contain a signed informed consent to treat. A review of patient #8’s EMR, with an admission date of 1/30/24, failed to contain a signed informed consent to treat. During an interview on 4/9/24 at 3:11 p.m., staff member O said a consent for treatment should be signed with each admission. Staff member O stated if a patient was moving from inpatient status to swing bed within the facility, it might be missed.”

“RECORDS SYSTEM CFR(s): Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings; This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to ensure a medical doctor co-signed and assumed full responsibility for the history and physical, when a patient was admitted to the facility by a mid-level provider for 17 (#1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) of 20 sampled residents. This deficient practice had the potential to affect all patients admitted to the facility by a mid-level provider. Findings include: A review of patient #1’s medical record showed an admission date of 8/20/21. A history and physical was performed by staff member K, but was not co-signed by staff member J. A review of patient #3’s medical record showed an admission date of 4/2/24. A history and physical was performed by staff member M, but was not co-signed by staff member J. A review of patient #4’s medical record showed an admission date of 3/28/24. A history and physical was performed by staff member K, but was not co-signed by staff member J. A review of patient #5’s medical record showed an admission date of 1/31/24. A history and physical was performed by staff member K, but was not co-signed by staff member J. A review of patient #6’s medical record showed an admission date of 1/19/21. A history and physical was performed by staff member K, but was not co-signed by staff member J. A review of patient #7’s medical record showed an admission date of 3/21/24. A history and physical was performed by staff member L, but was not co-signed by staff member J. A review of patient #8’s medical record showed an admission date of 1/30/24. A history and physical was performed by staff member M, but was not co-signed by staff member J. A review of patient #9’s medical record showed an admission date of 8/4/23. A history and physical was performed by staff member K, but was not co-signed by staff member J. A review of patient #10’s medical record showed an admission date of 5/12/20. A history and physical was performed by staff member M, but was not co-signed by staff member J. 44769 A review of patient #11’s medical record showed an admission date of 4/24/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J. A review of patient #12’s medical record showed an admission date of 12/15/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J. A review of patient #13’s medical record showed an admission date of 6/23/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J. A review of patient #14’s medical record showed an admission date of 3/3/24. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J. A review of patient #15’s medical record showed an admission date of 11/2/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J. A review of patient #16’s medical record showed an admission date of 12/31/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J. A review of patient #17’s medical record showed an admission date of 10/19/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J. A review of patient #18’s medical record showed an admission date of 12/10/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J. During an interview on 4/9/24 at 2:06 p.m., staff member J stated he had not co-signed history and physicals performed by mid level practioneers at the facility.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (vi) Communication and collaboration with the antibiotic stewardship program. This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to effectively communicate antibiotic stewardship to facility staff. This deficient practice had the potential to harm patients from unnecessary antibiotic use. Findings include: During an interview on 4/10/24 at 4:00 p.m., staff member P stated she had not presented any antibiotic stewardship training to facility staff. A review of a facility policy, titled, “Antimicrobial Stewardship Program,” with a revision date of 2/26/24, showed: “POLICY: The Antimicrobial Stewardship Program (ASP) will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing which may include but is not limited to the following activities: ... 2. Educational Activities Education to prescribers and other relevant staff regarding evidence-based guidelines or best practices including antimicrobial management should occur upon hire and at minimum annually thereafter. ...” A request for antibiotic stewardship training documentation was submitted to staff member N on 4/9/24 at 5:25 p.m. No documentation was provided prior to the end of the survey.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for: (i) The development and implementation of a facility-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics. This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to develop and implement an antibiotic stewardship program. This deficient practice had the potential for emergence of antimicrobial-resistant bacteria to be introduced into the facility. Findings include: During an interview on 4/10/24 at 4:00 p.m., staff member P stated she had not been, “real educated” on an antibiotic control program. During an interview on 4/10/24 at 4:00 p.m., when asked if the facility’s antibiotic stewardship program was based on nationally recognized guidelines, staff member P stated, “I have not done anything like that.” A review of a facility policy, titled, “Antimicrobial Stewardship Program,” with a revision date of 2/26/24, showed: “POLICY The Antimicrobial Stewardship Program (ASP) will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing which may include but is not limited to the following activities: 1. Streamlining or de-escalation therapy 2. Educational activities 3. Antimicrobial management protocols and guidelines 4. Surveillance monitoring 5. Formulary restrictions PURPOSE: To comply with evidence-based guidelines or best practices regarding antimicrobial prescribing and promote rational and appropriate antimicrobial therapy while improving clinical outcomes while minimizing unintentional side-effects of antimicrobial use, including toxicity and emergence of resistant organisms. ... 3. Antimicrobial Management Protocols and Guidelines ASP shall develop/update implement evidence-based practice protocols and guidelines that incorporate local microbiology and resistance patterns. Recommendations shall be presented to the Infection Control Committee and/or P&T Committee for approval as needed. ...””

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for:] (ii) All documentation, written or electronic, of antibiotic stewardship program activities. This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to document antibiotic stewardship activities. This deficient practice had the potential for the development of antimicrobial-resistant bacteria. Findings include: During an interview on 4/10/24 at 4:00 p.m., staff member P stated she had no documentation for the monitoring or use of antibiotics in the facility. A review of a facility policy, titled, “Antimicrobial Stewardship Program,” with a revision date of 2/26/24, showed: “... PROCEDURE: The program assessment and strategic plan is based on the [Organization Name] guidelines for Antimicrobial Stewardship. The outcomes and impact of the program shall be tracked and reported to the Medical Staff at a quarterly minimum to include improved utilization of antimicrobials and cost effectiveness. The following activities are to be carried out by the ASP team. ...””

“SNF SERVICES CFR(s): The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: §485.645(d)(1) Resident Rights (§483.10(b)(7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2) and (4), (f)(4)(ii) and (iii), (g)(8) and (17), (g)(18) introductory text, (h) of this chapter). “ §483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident’s behalf. The court-appointed resident representative exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. “ §483.10(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. “ §483.10(c)(2)(iii) The right to be informed, in advance, of changes to the plan of care. “ §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. “ §483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician. (1) The physician must be licensed to practice, and (2) If the physician chosen by the resident refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in paragraphs (d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment. (3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. (4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the resident’s preferences, if any, among options. (5) If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility must honor that choice. “ §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. “ §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. “ §483.10(f)(4)(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident’s right to deny or withdraw consent at any time; “ §483.10(f)(4)(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent at any time; “ §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident’s own expense. “ §483.10(g)(17) The facility must- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. “ §483.10(g)(18)[introductory text only] The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. “ §483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. (3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident’s medical, social, and administrative records in accordance with State law. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to provide a written explanation of the patient’s rights prior to a swing bed admission for 6 (#s 3, 4, 7, 8, 9, and 10) of 20 sampled residents. This deficient practice had the potential to affect the patient’s ability to exercise their rights. Findings include: A review of patient #3’s EMR, with an admission date of 4/2/24, failed to contain a signed copy of the patient rights. A review of patient #4’s EMR, with an admission date of 3/28/24, failed to contain a signed copy of the patient rights. A review of patient #7’s EMR, with an admission date of 3/1/24, failed to contain a signed copy of the patient rights. A review of patient #8’s EMR, with an admission date of 1/30/24, failed to contain a signed copy of the patient rights. A review of patient #9’s EMR, with an admission date of 8/4/23, failed to contain a signed copy of the patient rights. A review of patient #10’s EMR, with an admission date of 5/12/20, failed to contain a signed copy of the patient rights. During an interview on 4/9/24 at 2:28 p.m., staff member O said she would not expect to see patient rights forms signed for each admission. Staff member O stated, “If they transfer from swing bed to inpatient and then back to their previous status as swing bed, they would have the same rights and I would not expect to have the patient sign a new patient rights document each time.””

“GRIEVANCES CFR(s): § 485.614(a)(2) Grievances The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to inform all patients whom to contact to file a grievance for 3 (#s 4, 6, and 10) of 20 sampled residents. This deficient practice had the potential to limit a patient’s rights to submit a grievance to the facility. Findings include: During an interview on 4/9/24 at 7:32 a.m., patient #4 said he did not remember receiving any information on filing a grievance. Patient #4 said he had no need to file a grievance, but it was good information to provide. A review of resident #4’s EMR, with an admission date of 3/28/24, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review or resident #6’s EMR, with an admission date of 1/19/21, showed no information was provided to the patient or the patient’s representative about filing a grievance. A review or resident #10’s EMR, with an admission date of 5/12/20, showed no information was provided to the patient or the patient’s representative about filing a grievance. During an interview on 4/9/24 at 3:11 p.m., staff member O said all patients should have been provided information on filing a grievance. STaff member O stated the information and attestation documentation was supposed to be provided in the patient’s admission packet.”