Ruby Valley Medical Center

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 40068 Based on interview and record review the facility failed to implement the initial and annual training of the EP program to all staff members, consistent with each team members’ expected roles during an emergency or a disaster. This deficiency affects all the occupants and staff in the facility. Findings include: 1. Record review of the facility EP plan and training documents on 5/13/24 revealed, the facility did not have documentation that staff training for the EP plan was conducted initially for new staff and every other year for all current staff. During an interview on 5/13/24 at 12:46 p.m., staff member C stated he did not have a specific training program for emergency preparedness and did not have documentation of staff who have completed emergency preparedness training upon hire and every two years after.”

“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 survey was performed on 5/13/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, Chapter 18 New Healthcare Occupacies, 2012 Edition, and those mandatory Codes referenced by that edition. The building construction type was found to be Type V (111) and contains three smoke compartments. No new construction has occurred since the last survey on 4/8/19. The facility is connected to a medical clininc and a two hour separation is present. The facility utilizes the therapy department on the medical clinic side, therefore, the entire facility was surveyed. The facility is licensed for 5 beds and at the time of surveythe census was 4 patients. These requirements were not met as evidenced by the following deficiencies:”

“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 survey was performed on 5/13/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, Chapter 19 Existing Healthcare Occupancies, 2012 Edition, and those mandatory Codes referenced by that edition. The building construction type was found to be Type V (111) and contains three smoke compartments. No new construction has occurred since the last survey on 4/8/19. The facility is connected to a medical clininc and a two hour separation is present. The facility utilizes the therapy department on the medical clinic side, therefore, the entire facility was surveyed. The facility is licensed for 5 beds and at the time of surveythe census was 4 patients. These requirements were not met as evidenced by the following deficiencies:”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 40068 Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 14.4.5 (6). This deficiency affects all smoke compartments at the facility. Findings include: During a review of the most recent facility fire alarm inspection on 5/13/24, the fire alarm system was inspected on 10/24/23. There was no indication either written on the batteries or in the panel that the six-month voltage test had been completed by the facility semi-annually.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 40068 Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 14.4.5 (6). This deficiency affects all smoke compartments at the facility. Findings include: During a review of the most recent facility fire alarm inspection on 5/13/24, the fire alarm system was inspected on 10/24/23. There was no indication either written on the batteries or in the panel that the six-month voltage test had been completed by the facility semi-annually.”

“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: 40068 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) replace or test sprinkler gauges every 5 years in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.2, c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3). This deficiency affected all staff and patients at the facility. Findings include: 1. Review of the facility’s sprinkler inspections on 5/13/24 showed the facility had not had an internal inspection of the sprinkler piping or the gauges to the sprinkler system had been recalibrated or replaced in the last 5years. The last internal inspection was in 2018. During an interview on 5/13/24 at 10:32 a.m., staff member B stated the sprinkler company was going to replace the sprinkler gauges at the same time the internal inspection was completed. Staff member B stated he knew it should have been done. 2. During an observation on 5/13/24 at 11:46 a.m., the gift storage room was inspected. The storage room had a missing ceiling tile.”

“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: 40068 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) replace or test sprinkler gauges every 5 years in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.2, and c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3). This deficiency affected all staff and patients at the facility. Findings include: 1. Review of the facility’s sprinkler inspections on 5/13/24 showed the facility had not had an internal inspection of the sprinkler piping or the gauges to the sprinkler system had been recalibrated or replaced in the last 5years. The last internal inspection was in 2018. During an interview on 5/13/24 at 10:32 a.m., staff member B stated the sprinkler company was going to replace the sprinkler gauges at the same time the internal inspection was completed. Staff member B stated he knew it should have been done. 2. During an observation on 5/13/24 at 12:03 p.m., the charting room was inspected. There was a circular hole cut out of the ceiling tile.”

“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. 18.7.1.4 through 18.7.1.7 This Standard is not met as evidenced by: 40068 Based on record review, the facility failed to conduct fire drills for every shift in every quarter, as well as consistently documented the drill simulation under varied conditions in accordance with NFPA 101, 2012 Edition, section 18.7.1.6 and 18.7.2.2. This deficiency affects all residents and staff at the facility. Findings include: During a review of facility fire drills on 5/13/24 it was determined the facility was missing the following fire drills: a) First and second shift of the second quarter of 2023 (April - June 2023). b) First and second shift of the fourth quarter of 2023 (October - December 2023). Review of the facility’s fire drills showed there was not a description of the simulation of the fire drill, therefore it could not be determined the fire drills were being simulated under varied conditions. During an interview on 5/13/24 at 10:32 a.m., staff member B stated he did not usually write a summary of the drill and under what conditions the drill was being performed.”

“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: 40068 Based on record review, the facility failed to conduct fire drills for every shift in every quarter, as well as consistently documented the drill simulation under varied conditions in accordance with NFPA 101, 2012 Edition, section 19.7.1.6 and 19.7.2.2. This deficiency affects all residents and staff at the facility. Findings include: During a review of facility fire drills on 5/13/24 it was determined the facility was missing the following fire drills: a) First and second shift of the second quarter of 2023 (April - June 2023). b) First and second shift of the fourth quarter of 2023 (October - December 2023). Review of the facility’s fire drills showed there was not a description of the simulation of the fire drill, therefore it could not be determined the fire drills were being simulated under varied conditions. During an interview on 5/13/24 at 10:32 a.m., staff member B stated he did not usually write a summary of the drill and under what conditions the drill was being performed.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 40068 Based on record review, the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 101 2012 Edition, Section 9.1.3.1 and NFPA 110, Section 8.3.8. This deficiency affects the entire facility. Findings include: Review of the emergency generator inspection records on 5/13/24, revealed there was no documentation showing the annual diesel fuel supply quality test was conducted within the last year.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 40068 Based on record review, the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 101 2012 Edition, Section 9.1.3.1 and NFPA 110, Section 8.3.8. This deficiency affects the entire facility. Findings include: Review of the emergency generator inspection records on 5/13/24, revealed there was no documentation showing the annual diesel fuel supply quality test was conducted within the last year.”

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 35356 Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for the Provision of Services. Based on observation, interview, and record review, the facility failed to: - Develop policies and procedures that reflect goals and processes for the Quality Assurance Performance improvement (QAPI) program; and failed to develop policies and procedures that reflect the services provided and processes in place for the pain management program (See C1006). - Ensure the facility’s established group of professionals reviewed patient care policies for their radiological patient care services biannually (See C1008). - Establish and implement policy and procedures for following provider ordered diets; and failed to ensure staff followed dietary orders as ordered by the provider (See 1020). - Develop and implement policies and procedures to include identifying hazardous radiation areas; and failed to ensure clear signage was posted on the entrance to the radiology department, identifying a hazardous radiation area (See C1030). - Ensure nutritional services were provided to meet the nutritional needs of inpatients by ensuring a dietitian reviewed and approved dietary menus supplied by the contracted meal service providers prior to the implementation of the menu (See C1040).”

“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: 45448 Based on observation, interview, and record review, the facility failed to ensure expired medications and supplies in the emergency crash cart were replaced prior to the expiration date. This deficient practice had the potential to affect any emergency room patient requiring the use of these supplies. Findings include: During an observation on 5/6/24 at 1:43 p.m., the following items were found to be expired in the emergency room crash cart: - Dopamine 800/500 ml IV bag, expiration 5/1/24 - Intranasal Mucosal Atomization Device, expiration 3/29/24 During an interview on 5/6/24 at 1:58 p.m., staff member C said all emergency medication was located within the emergency crash cart and the pharmacy was responsible for stocking medications within the crash cart. Staff member C said nursing staff were assigned, each shift, to ensure supplies and emergency equipment were available and ready for use. Review of a facility policy, “Removing Outdated Products,” dated 2/26/20, showed: “ ... All drug storage areas of the hospital will be inspected for drugs that are unusable. These areas of inspections shall include emergency carts, automated dispensing machines, Anesthesia drug boxes, and other patient care unit stock areas, if applicable. The nursing staff will remove all unsuitable drugs from each area. ...””

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 35356 Based on observation, interview, and record review, the facility failed to establish written policies and procedures for establishing strategies to ensure the maintenance of all essential mechanical, electrical, and patient-care equipment utilized by the facility to include critical care equipment not managed by an alternative equipment management (AEM) program; and failed to ensure all essential medical equipment was identified and maintained through a facility established maintenance strategy when not maintained by an AEM program. The accumulative effect of this deficiency had the potential to affect all patients’ services with these devices. Findings include: 1. Established Equipment Maintenance Policy and Procedures A review of the facility’s policy and procedure titled Equipment Maintenance, with a review date of 5/16/22, failed to include strategies to ensure the maintenance of all essential mechanical, electrical, and patient-care equipment utilized by the facility was established; and failed to include equipment which would not be managed by an AEM program. During an interview on 5/7/24 at 3:00 p.m., staff member F stated there were no additional policy and procedures established for the periodic maintenance of medical equipment. 2. Periodic Maintenance of Patient-Care Equipment not on AEM During an observation and interview on 5/6/24 at 1:43 p.m., the portable ventilator located within the emergency department failed to contain a biomedical sticker. Staff member C said the biomedical checks were a contracted service and the company providing the service was responsible for maintaining the biomedical equipment checks. Review of the facility’s Active Equipment list maintained through the facility’s established AEM program, showed: Hamilton Medical, Vent Support System, Serial number 1275, was listed on the active equipment list. However, there was no corresponding equipment maintenance ticket for the Hamilton Vent Support System. During an interview on 5/6/24 at 3:15 p.m., staff member F stated although the ventilator, located in the emergency department, was identified on the facility’s active AEM list; the AEM management program did not manage equipment considered “anesthesia” equipment. Staff member F stated since the ventilator in the emergency department was considered “anesthesia” equipment it was not maintained by the AEM program. Staff member F stated he did not have an alternative means in place for the periodic maintenance of such equipment. He stated it was the responsibility of the department heads to ensure that equipment was maintained and working correctly. Review of the Hamilton - 1 Service Manual, Chapter 6, Preventative Maintenance and Testing, dated 10/26/20, showed, “... Preventative maintenance ensures that the unit is kept in optimal condition and that any defective parts are replaced before they can cause a loss of service. It also ensures that you have the latest software version. You must perform the preventative maintenance schedule: - after replacing a component; - once a year or every 5000 operating hours, whichever comes first. ...” During an interview on 5/7/24 at 9:38 a.m., staff member B stated the department heads run safety checks on the equipment, but they do not ensure the periodic maintenance of the equipment in the departments. Staff member B stated they checked with the Hamilton servicing department for the ventilator in the emergency department, and that ventilator had not had a periodic maintenance in over a year.”

“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: 45448 Based on interview and record review, the facility failed to develop policies and procedures that reflect goals and processes for the Quality Assurance Performance improvement (QAPI) program; and failed to develop policies and procedures that reflect the services provided and processes in place for the pain management program. These deficient practices had the potential to affect patients receiving pain management treatment and all patients receiving care within the facility. Findings include: 1. A request was made on 5/6/24 at 10:11 a.m., for the facility Quality Assurance plan. The documentation was not received by the end of the survey. During an interview on 5/8/24 at 12:21 p.m., staff member B said he was unable to locate the policies and procedures for the Quality Assurance program for the facility. 2. Review of a facility policy, Interventional Pain Procedures, did not contain an effective date, a revision date, a review date, or an approval by any individual. The policy did not contain patient care requirements, preprocedural requirements, a list of procedures performed, protocols for all procedures performed, patient consents and releases, patient identification procedures, patient scheduling, personnel policies unique to the procedure, housekeeping requirements, and safety practices. During an interview on 5/8/24 at 11:11 a.m., staff member K said he remembered the board discussing the development of the pain management program but did not remember policies or procedures being discussed with the board. During an interview on 5/8/24 at 11:49 a.m., staff member C said there was a detailed process that each patient goes through prior to a pain procedure being performed. She was not aware the process was not contained withing the policies and procedures until she provided the surveyor with the policy for pain management.”

“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: 35356 Based on interview and record review, the facility failed to ensure the facility’s established group of professionals reviewed patient care policies for their radiological patient care services biannually. This deficient practice had the potential to affect all patient care services provided by the facility’s radiology department. Findings include: A review of the facility’s patient care policy and procedures on 5/8/24, for section, Medical Imaging, showed the following policy and procedures were last reviewed by the facility’s Policy Committee on 3/21/22: - Continuing Education, code number: 11.100, - Department Cleaning, code number: 11.101, - Diagnostic Materials, code number: 11.102, - Radiology Dress Code, code number: 11.103, - Scope and Services, code number: 11.104, - Electrical Safety, code number: 11.105, - Enforcing Standards, code number: 11.106, - Hours of Operations, code number: 11.107, - Maintenance, code number: 11.108, - Portable Exams, code number: 11.109, - Provider Orders, code number: 11.110, - Release of Information, code number: 11.111, - Reports, Confidentiality, Retention, code number: 11.112, - Operation of Machines, code number: 11.114, - Trauma CT Scanning, code number: 11.115, - Radiation Safety of Pregnant Patient, code number: 11.116. During an interview on 5/7/24 at 10:23 a.m., staff member C stated the facility had a group of professionals who were responsible for reviewing the patient care policy and procedures at least, every two years, or based on a review schedule. Staff member C stated she was not sure why the policy and procedures for the imaging services were not reviewed in the last two years.”

“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: 35356 Based on observation, interview, and record review, the facility failed to establish and implement policy and procedures for following provider ordered diets; and failed to ensure staff followed dietary orders as ordered by the provider for 1 (#12) of 20 sampled patients. Findings include: 1. A request for the facility’s policy and procedure for following provider ordered diets was submitted on 5/8/24 at 4:00 p.m. A policy and procedure was not provided by the end of the survey. During an interview on 4/8/24 at 4:45 p.m., staff member C stated the facility did not have an established policy and procedure for following diet orders as ordered by the provider. 2. During an observation on 5/8/24 at 9:21 a.m., patient #12 was in his room. There was a tray with food placed next to his bed. The tray was observed to have scrambled eggs on the plate. Review of patient #12’s provider orders showed a full liquid diet was ordered on 4/23/24. A review of the patient’s provider orders from, 4/23/24 to 5/8/24, did not show the provider changed the patient’s order from a full liquid diet to a regular diet. During an interview on 5/8/24 at 4:00 p.m., staff member E stated she had observed patient #12 eating a regular diet that morning when she observed the patient eating scrambled eggs for breakfast. Staff member E stated there was not a provider order in the patient’s medical record to change the patient’s diet from a full liquid diet to a regular diet. Staff member E stated it was the expectation for nursing staff to follow dietary orders as ordered by the provider. Staff member E stated it appeared the nurse put in a meal request for a regular diet instead of the ordered full liquid diet.”

“RADIOLOGY SERVICES CFR(s): §485.635(b)(3) Radiology services. Radiology services furnished by the CAH are provided by personnel qualified under State law, and do not expose CAH patients or personnel to radiation hazards. This Standard is not met as evidenced by: 35356 Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to include identifying hazardous radiation areas; and failed to ensure clear signage was posted on the entrance to the radiology department, identifying a hazardous radiation area. This deficient practice had the potential to affect all patients and staff utilizing the radiation services. Findings include: 1. On 5/7/24 at 4:00 p.m., a request was made for a policy regarding signage for radiation hazards in the diagnostic imaging department. No policy was provided by the end of the survey. During an interview on 5/8/24 at 9:00 a.m., staff member C stated she could not find a policy and procedure regarding identifying hazardous radiation areas for the radiology department. 2. During an observation on 5/7/24 at 1:30 p.m., there were no signs showing radiation hazards that included the universal sign for radiation in the diagnostic imaging department for either entrance to the diagnostic imaging department. During an interview on 5/7/24 at 2:10 p.m., staff member I stated they did not have universal signage posted at either entrance of the diagnostic imaging department to identify potential radiation hazards.”

“AGREEMENTS AND ARRANGEMENTS CFR(s): [The CAH has agreements or arrangements (as appropriate) with one or more providers or suppliers participating under Medicare to furnish other services to its patients, including-] (iii) Food and other services to meet inpatients’ nutritional needs to the extent these services are not provided directly by the CAH. This Standard is not met as evidenced by: 45448 Based on observation, interview and record review, the facility failed to ensure nutritional services were provided to meet the nutritional needs of inpatients by ensuring a dietitian reviewed and approved dietary menus supplied by the contracted meal service providers, prior to the implementation of the menu. This deficient practice had the potential to affect all patients receiving meal services provided by the facility. Findings include: During an observation and interview on 5/6/24 at 11:48 a.m., staff member M was observed removing a plastic cover from a plastic disposable bowl, then placing the container and its contents in a microwave oven for reheating. Staff member M said meals were provided for patients from an outside source, and the facility did not have kitchen or dietary staff. Staff member M said the facility lunch meal was provided by the community senior center and the breakfast and dinner meals were provided by the community long-term care facility. Staff member M said meals were delivered to the facility and had lost their warmth, so they were reheated in the microwave prior to serving. Staff member M stated if a patient had special dietary needs, the facility would notify the center and provide the information. The meal would be delivered and noted with the appropriate diet. During an interview on 5/6/24 at 12:53 p.m., staff member B said he was not sure if the facility contracted dietician approved the menu for the meals provided by the community senior center. Staff member B stated the long-term care facility menus were overseen by the dietitian contracted from another facility and provided oversight for the long-term care facility. During an interview on 5/7/24 at 10:35 a.m., NF1 said the senior center did not have a dietician to provide oversight of the senior center menu. NF1 said she would use the nurses to help her with what was needed to provide any specialized diets. During an interview on 5/7/24 at 10:48 a.m., NF2 said the long-term care facility menus were approved by a contracted dietitian that comes to the facility once a month. NF2 said the dietitian was available by phone when staff had questions and was available to the facility for an onsite visit within an hour if needed. During an interview on 5/8/24 at 12:52 p.m., staff member Z said he did not provide oversight of the senior center or long-term care menus. Staff member Z stated he was contracted to provide nutritional services to the facility swing bed patients. Staff member Z said he provided all services to the facility via zoom and had not physically been to the facility. During an interview on 5/8/24 at 1:59 p.m., NF3 said the facility had contracted their services to provide nutritional evaluations and management for swing bed patients. No services for menu approvals or oversight were contained in the contract services provided. Review of a facility document, “Dietitian Services Agreement,” signatures dated 1/18/22, showed: “ ... Exibit A, Description of Services ... 5. Assist with changes to, substitutions of, and approval of all regular and therapeutic menus used in the facilities, including annual reviews thereof. “”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to follow their established policy and procedures for ensuring nursing requirements for Advanced Cardiovascular Life Support (ACLS) and Pediatric Advanced Life Support (PALS) certifications; and failed to ensure nursing staff assigned to work in the emergency department with the potential of administering emergency care services for pediatric and adult patients maintained an active ACLS and PALS certification for 4 (staff members B, Q, R, X) of 16 reviewed staff members. This deficient practice had the potential to affect all adult and pediatric patients in need of emergent advanced life support. Findings include: A review of the facilities personnel requirements document titled, [Registered Nurse] Job Description, showed, “The Registered Nurse is responsible for the administration of professional nursing care to all patients in the hospital, including acute care patients, swing bed patients, and patients presenting to the Emergency and Out-Patient departments either personally or by delegation and supervision of supporting nursing personnel. The Registered Nurse works under the direction of the Chief Nursing Officer and practitioners granted privileges by the Board of Directors... The following is a list of requirements for licensure and certification for the Registered Nurse to maintain to continue working as an employee of Ruby Valley Hospital: ... Maintains a current Advanced Cardiac Life Support (ACLS) certification. ... Is encouraged to obtain certifications in Pediatric Advanced Life Support, Trauma and Advance Trauma Life Support and any other self-motivated certification to expand the registered nurse’s knowledge base in rural health care; ...” During an interview on 5/7/24 at 10:23 a.m., staff member C stated it was the expectation for staff to have ACLS and PALS certifications if working in the emergency department. She stated nursing staff who worked in the emergency department would be expected to have the appropriate qualifications and certifications for addressing emergent patient care situations for both adult and pediatric patients. Staff member C stated there were currently several nursing staff who had expired PALS certifications, and they were scheduled for the full two-day certification course on 6/18/24, instead of the recertification course. A review of the facility’s personnel files on 5/8/24 at 10:49 a.m., showed the following staff did not have PALS certification on file: Staff members Q, R, and X. Staff member B had a PALS certification on file which had expired on 10/31/22. A review of the facility’s personnel files on 5/8/24 at 10:49 a.m., showed staff member R did not have an ACLS certification on file. A request was submitted on 5/8/24 at 11:00 a.m., to provide additional PALS and ACLS certifications for staff members B, Q, R, and X. This documentation was not provided by the end of the survey.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45448 Based on observation, interview, and record review, the facility failed to ensure timely and routine biological spore testing of the autoclave sterilizers used to sterilize patient care instruments; failed to include chemical indicators within sterilization pouches for verification of sterilization process; and failed to establish a process for identifying equipment processed by the autoclave in the event of a sterilizer malfunction, or for tracking of hospital acquire infections. These deficient practices had the potential to affect all patients receiving care withing the facility that required the use of facility sterilized instrumentation. Finding include: During an observation on 5/6/24 at 1:58 p.m., multiple sterilization pouches containing sterile instruments were inspected within the emergency rooms. All pouches were observed to not contain a sterilization indicator within the instrument pouch. Some of the pouches contained a load number and initials of the individual that performed the sterilization, other pouches contained only initials, and some of the pouches had nothing written on the pouch. During an interview on 5/7/24 at 1:38 p.m., staff member AA was observed placing clean and dry instruments into the sterilization pouches. Staff member AA then placed the pouches into the autoclave for sterilization. She had not been instructed to place chemical indicator strips into to the pouches for the purpose of sterilization verification. Staff member AA said she will do biological testing on the autoclaves monthly and does not do a biological test with every load. She stated autoclaves were turned off when not in use. Staff member AA said the biological tests take 24 hours to read the results so she did not do a sterilization load the same day the biological tests were performed. Staff member AA said the autoclave would provide a printout of the sterilization cycle and she would print the load number on the instrument package. She stated she did not have a tracking system for the biological testing with the loads she would run. Staff member AA said she was not aware of any tracking of instruments to patient use for infection control monitoring. Staff member AA said she had not been provided any formal education on sterilization practices and recommendations. Staff member AA stated she was trained by the individual previously responsible for the sterilization of facility instruments. A request was made on 5/7/24 at 2:40 p.m. for instrument cleaning and processing. A policy titled, Reuseable Articles Requiring Sterile Processing, was provided. The policy stated to refer to the guidelines of “Autoclave Procedure”. The Autoclave Procedure guidelines were not provided by the end of the survey. A record review of the “Tuttnauer Operation & Maintenance Manual,” for electronic tabletop autoclaves, showed: “ ... 7. Preparation Before Sterilization ...10. Place a sterilization indicator in each tray or inside each wrapped package. 11. At least once a week use a biological spore test (Bacillus Stearothermophilus) in any load to insure proper sterilization. ...””

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): §485.643(a) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the CAH. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the CAH, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the CAH for this purpose; This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their facility’s Quality Assurance and Performance Improvement (QAPI) Program. This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include: During an interview on 5/6/24 at 10:30 a.m., staff member B stated the facility’s OPO program was not currently included into their QAPI program. A review of the facility’s QAPI meeting minutes showed no documentation for the inclusion of the OPO program.”