St Luke Community Hospital

“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: 46400 Based on interview, record review, and policy review, the hospital failed to comply with the requirements in 42 CFR 489.24 (refer to Appendix V). The hospital failed to provide an appropriate Medical Screening Exam (MSE) by a Qualified Medical Professional (QMP) within the capabilities of the hospital’s Emergency Department (ED) to determine whether an emergency medical condition existed for 1 (#21) of 21 sampled patients; and failed to maintain a central log on each individual who presented to the emergency department seeking assistance whether they refused treatment, were refused treatment, were transferred, stabilized, admitted or discharged for 1 (#21) of 21 sampled patients. Findings include: Patient #21 presented to the emergency department of St Luke Community Hospital on 6/12/26 after a clinic visit, during which the provider recommended she be seen for further evaluation of her shortness of breath at the nearest emergency room. Patient #21 was told by staff at St Luke Community Hospital ED that it would be better for her to be seen at [Hospital B] because [Hospital B] was affiliated with the clinic she had come from and would already have her records. Patient #21 did not receive an MSE to determine whether an EMC (Emergency Medical Condition) existed or not. [C-2406]. Review of St Luke Community Hospital’s Emergency Department log, dated 6/12/26, showed that patient #21 was not registered in the log. [C-2405]. Review of a facility policy titled Screening Exam/Triage policy, revision date 6/14/24, showed: “ ... Patients presenting for care will have a brief screening examination performed by an RN in collaboration with a physician, nurse practitioner, or physician assistant in order to determine the presence or absence of an emergency medical condition. To facilitate the timeliness of the exam, tasks such as vital signs ... may be performed by a trained aide ...””

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 46400 Based on interview and record review, the facility failed to maintain a central log on each individual who presented to the emergency department seeking assistance whether they refused treatment, were refused treatment, were transferred, stabilized, admitted or discharged for 1 (#21) of 21 sampled patients. Findings include: During an interview on 7/21/26 at 10:50 a.m., patient #21 stated there was a lack of communication when she arrived at St Luke Community Hospital Emergency Department. On the advice of a nearby clinic physician, she was referred to the facility for further evaluation of her shortness of breath. After discussions with staff at St Luke Community Hospital Emergency Department about the location of her medical records, patient #21 sought evaluation at another facility. During an interview on 7/15/26 at 12:10 p.m., staff member F stated she overheard a conversation where patient #21 had told the triage nurse she did not realize St Luke Community Hospital and [Hospital B-associated clinics] were not affiliated. Staff member F stated she went over to speak with patient #21, stressing that they would be happy to evaluate her in their Emergency Department and could request her medical records from [Hospital B]. Staff member F stated that patient #21 was not registered in their system and that there was no place to document this conversation. Review of St Luke Community Hospital Emergency Department log, dated 6/12/26, did not show that patient #21 was registered. There were no vital signs recorded, and no documentation that she had declined to be seen. Patient #21 did not have a medical record at the facility.”

“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: 46400 Based on interview and record review, the facility failed to provide an MSE to a patient presenting in the emergency department for 1 (#21) of 21 sampled patients. Findings include: During an interview on 7/21/26 at 10:35 a.m., NF3 stated patient #21 was experiencing shortness of breath and weight gain. She was having significant difficulty breathing without an obvious reason, and he did not feel comfortable sending her home for the weekend without a more comprehensive workup available in the Emergency Department setting. NF3 recommended that patient #21 go to the nearest Emergency Department, St Luke Community Hospital, in Ronan. NF3 stated report was called in to staff member F. During an interview on 7/21/26 at 10:50 a.m., patient #21 stated there was a lack of communication when she arrived at St Luke Community Hospital Emergency Department. Patient #21 stated the nursing staff had no knowledge that her doctor had called over. Patient #21 stated that staff told her they would treat her in the Emergency Department, but it would be better for her to be where all her medical records were at [Hospital B]. During an interview on 7/15/26 at 12:10 p.m., staff member F stated she had received report from the nearby clinic that a patient was being sent over for evaluation. Staff member F stated that patient #21 told the triage nurse she did not realize St Luke Community Hospital and [Hospital B-associated clinics] were not affiliated. Staff member F stated she overheard this conversation and went over to speak with patient #21, stressing that they would be happy to see her in their Emergency Department and could request her medical records from [Hospital B]. Staff member F stated that patient #21 was not registered in their system and that there was no place to document this conversation. The patient indicated she was encouraged to seek emergency care at Hospital B, whereas the physician indicated she encouraged the patient to be seen at St. Luke Community Hospital. There was no documentation that the patient was informed of the risks of leaving without an MSE and no documentation of staff discussions with the patient indicating the patient was encouraged to stay. Review of [Hospital B’s] Emergency Department log, dated 6/12/26, showed patient #21 presented on 6/12/26 at 6:33 p.m. Patient #21 was triaged at acuity level 3 with presenting symptoms of an elevated respiratory rate and blood pressure. She was provided an MSE that included extensive labs and radiology testing. She was diagnosed with pulmonary arterial hypertension (high blood pressure in the vessels of the lungs). Review of the facility policy, Screening Exam/Triage, with a revision date of 6/14/24, showed: “ ... Patients presenting for care will have a brief screening examination performed by an RN in collaboration with a physician, nurse practitioner, or physician assistant in order to determine the presence or absence of an emergency medical condition. To facilitate the timeliness of the exam, tasks such as vital signs ... may be performed by a trained aide ...””

“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: 45448 Based on interview, record reviews, and review of facility documents, the facility failed to comply with the conditions of participation outlined in §489.20 and related requirements at 489.24: (refer to Appendix V). The facility failed to provide a medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department to determine if an emergency medical condition existed for two patients (#’s 11 and 24) of 24 sampled patients. Findings include: Review of facility policy, “Admission to Emergency Department,” with a revision date of 4/2015, showed: “ In compliance with EMTALA regulations, Hospital will provide for appropriate medical screening examinations, provide necessary stabilizing treatment for emergency medical conditions and labor, provide for an appropriate transfer of the individual if the hospital does not have the capability or capacity to provide the treatment necessary to remove the emergency medical condition, not delay examination and/or treatment in order to inquire about insurance or payment status, accept appropriate transfers of individuals with medical emergencies if the hospital has the specialized capabilities not available at the transferring hospital and has the capacity to treat those individuals, and obtain or attempt to obtain informed written consent or refusal for examination, treatment or appropriate transfer. The facility will not take adverse action against a physician or qualified medical personnel who refuses to transfer an individual with an emergency medical condition or against an employee who reports a violation of the EMTALA requirements.” -Patient #11 did not receive a MSE (Medical Screening Examination) after seeking care in the emergency department. (Refer to C-2406) -Patient #24 did not receive an appropriate MSE in the emergency department after seeking care and before being discharged. (Refer to C-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: 45448 Based on interview, record review, and review of facility documents, the facility failed to provide a MSE for 1 (#11), and the facility failed to provide an appropriate MSE for 1 (#24) of 24 sampled patients. Findings include: 1. Emergency visit #1: Patient #11 was seen in the emergency department on 5/22/23 at 9:14 p.m. for a complaint of a sore throat. Patient #11 had experienced the sore throat for 4 hours and was concerned he may have had strep throat due to his history of strep throat. Patient #11 was assessed in triage at 9:19 p.m. by staff member H. Vital signs were temperature 97.7F, Pulse 85, Blood Pressure 130/76, and Oxygen saturation 98% on room air. Patient #11’s throat appeared irritated, but without white patches. Patient #11’s condition was assessed as non-urgent. Staff member H performed a POC strep test, results were documented as negative. Staff member H discharged patient #11 at 9:21 p.m. with instructions to increase fluids, quit smoking, take Tylenol for discomfort, and return to the clinic the following day if signs and symptoms worsen. Staff member H did not notify staff member I of patient #11’s admission to the emergency department, or the patient’s need for evaluation. Emergency visit #2: Patient #11 was seen a second time in the emergency department on 5/23/23 at 7:51 a.m. for complaint of continued sore throat with fever, chills, and worsening symptoms. Patient #11 was assessed in triage at 7:54 a.m. by staff member C. Vital signs for the patient included a temperature 99.1F, Pulse 91, Blood Pressure 136/77, and oxygen saturation of 97% on room air. The patient’s throat appeared reddened and irritated without noticeable white patches. Patient #11’s condition was assessed as non-urgent. Patient #11 reported he had been seen in the ED the previous night and “had not had the opportunity to see the physician.” Staff member K evaluated patient #11 and dictated a history and physical at 8:30 a.m. Patient #11 was diagnosed with strep pharyngitis and administered amoxicillin 500 mg and dexamethasone 10 mg in the ED. He was sent home with a prescription for amoxicillin 500 mg twice daily for 10 days. Patient #11 was discharged at 8:35 a.m. with instructions to follow-up with his primary physician in 7 to 10 days and return to the ED if symptoms worsen. During a phone interview on 3/27/24 at 10:20 a.m., staff member H stated she was currently working as a travel RN and worked at the facility a few shifts a month. Staff member H said she did not remember the incident with patient #11. Staff member H said when working as an ED nurse, she would sometimes see a patient and do a throat swab or other POC testing and give the patient the results. If the result was negative and the patient did not want to see the provider, or no interventions were required; she would discharge the patient with instructions. Staff member H said she would consider this a nurse visit, and document the patient was not seen by the physician. If the patient wanted to see the provider, she would notify the provider. Staff member H said, in her experience, she had seen facilities provide nurse visits and was told a nurse visit was allowed in this facility. Staff member H said she had no formal training or classes on EMTALA, but it was her understanding that patients requesting care had to be evaluated and treated. Staff member H stated she was not aware of an MSE being required for all patients presenting to the ED for care. Staff member H said she did not recall being informed about the incident or being provided further training following the incident. During a phone interview on 3/27/24 at 10:10 a.m., staff member I said he was not made aware of the incident with patient #11. Staff member I said the usual practice in the ED was to notify the physician once the patient had been brought back to an examination room in the ED. Staff member I said if he was in the ED at the time the patient was brought back to an examination room, he would immediately go to examine the patient, if he was available. Staff member I said if there were no patients in the ED, he would be in the physician call room. Nursing staff would usually contact him in the call room, and he would go and evaluate the patients. Staff member I said if the ED was not busy, he would have been in the call room at the time patient #11 was in the ED. He said if he was not contacted by nursing staff, he would have no idea what had occurred with patient #11. During an interview on 3/27/24 at 9:18 a.m., staff member C said patients that report to the ED, after convenient care hours, will be taken back to an examination room to be seen. Staff member I typically would come to the examination room with the nurse and start his evaluation at the same time the nurse was performing the triage evaluation. Staff member C said staff member I was in the call room at the time patient #11 arrived at the ED on 5/22/23. Staff member C said staff member H never notified staff member I of the arrival of patient #11. Staff member C said she was the nurse that cared for patient #11 on his second visit to the ED on 5/23/23. She stated she became aware of patient #11 not seeing a provider when she checked him in for his triage evaluation. Staff member C included the information as part of a patient complaint that included multiple issues with the care provided by staff member H. Staff member C then filed a “Risk Qual” document with the facilities incident reporting system and filled out a written complaint document with the patient information. Staff member C stated she contacted staff member H and provided her with verbal coaching which included appropriate customer service for patients seeking care at the facility and in-depth education on EMTALA. Staff member C said staff member H was newer to the facility and was only scheduled to work a few shifts a month. Staff member C said the incident was treated as a patient complaint and had not been identified as an EMTALA violation by the facility. Staff member C said the facility was made aware of the EMTALA violation in February during the facility recertification survey. Staff member C said during the investigation for the EMTALA violation, it was identified that new staff had not been receiving education on EMTALA requirements upon hire and only received education during the annual staff training in November of each year. Staff member C then started a QAPI project, in February, to include EMTALA training as part of the new hire orientation and added it to the skills checklist for new staff. Staff member C stated current ER nursing staff are scheduled to receive EMTALA training at the upcoming April ED staff meeting. Staff member C said it was a not regular practice for staff to swab a patient’s throat for testing without a physician order. Staff member C stated the only time a patient had a swab without a formal order was during COVID 19 testing at a testing area outside of the ED. During an interview on 3/27/24 at 3:00 p.m., staff member K said he was the provider that cared for patient #11 during his ED visit on 5/23/23. Staff member K said he did not remember patient #11 but had reviewed the charting for the visit. Staff member K said the occurrence for patient #11’s visit on 5/22/23 was not a typical occurrence. Staff member K stated a patient is seen by the ED nursing staff and triaged based on the vital signs and patient’s report. The nurse would give report to the physician, and a verbal order for any testing may be given at that time. Staff member K stated the only time a nurse would do swab testing without a patient being evaluated was during COVID 19, a standing order was in place. Staff member K said he diagnosed patient #11 with strep pharyngitis and treated him with amoxicillin and dexamethasone. Staff member K said patient #11 should have been evaluated by a physician on his 5/22/23 visit to the ER. During an interview on 3/27/24 at 1:38 p.m., staff member A said patient #11’s visit on 5/22/23 was documented and investigated by staff member C as a patient complaint. Staff member A stated a “Risk Qual” report was filed but was not found in the reporting system until the facility’s recertification survey, which occurred in February 2024. Staff member A stated the incident had been investigated and reported through the QAPI committee as a complaint and was also presented to the medical staff and the governing board as a complaint. The incident was presented at the last medical staff meeting in February, and the physicians were provided education on EMTALA during the meeting. Staff member A stated the governing board was presented with a report on all facility complaints during the last scheduled meeting and the board was given an opportunity to ask questions about the specific complaints. Staff member A said the new QAPI project was still in progress and the facility was currently orienting two new nurses to the ED using the new orientation checklist that had been developed. Record review of a verbal coaching report by staff member C, dated 5/24/23, showed: “Spoke with [staff member H] about patient situation that she treated as a nurse visit. Pt returned next day with c/o not being allowed to see MD. Informed her that we don’t do nurse visits in the ER, and potential for EMTALA violation. ...Stated understanding of need to contact MD with all pt arrivals.” Review of a facility document, “Patient/Visitor Feedback Form,” dated 5/23/24, showed patient #11 was seen the previous night by staff member H and was treated disrespectfully and “talked down to”. Patient #11 complained he was not given an option to see a doctor and was told to return to the clinic if he had worsening symptoms. Review of facility policy, “Admission to Emergency Department,” with a revision date of 4/2015, showed: “ In compliance with EMTALA regulations, Hospital will provide for appropriate medical screening examinations ... Policy: 1. A medical screening exam must be provided to any individual who presents on hospital property requesting care for an emergency medical condition regardless of diagnosis, financial status, race, color, national origin, or handicap. 2. Medial screening exams may be performed by non-physician medical professionals such as nursing personnel. The determination of the existence of an emergency medical condition is made by the physician based on the results of the screening exam...” Review of facility policy, “Physician Notification,” with a revision date of 4/2015, showed: “ ...1. All patients admitted to the Emergency Department will be assessed by an appropriate nursing staff member. An RN will assess all patients who present with an emergent or urgent condition. 2. The physician or qualified extender shall be notified by the RN regarding the admission of an Emergency Department patient...” Review of facility policy, “Medical Staff Obligations- Emergency Department,” with a revision date of 4/2015, showed: “ ...3. No treatments or tests will be completed, or medications administered without an order from the physician...” Review of a facility document, “ED/Trauma Committee Meeting Minutes,” dated 2/23/24, showed: “ ...EMTALA education was presented by [staff member C]...” Review of a facility document, “Board of Directors Meeting,” dated 2/26/24, showed: “ ...Risk Qual: A summary report was given to the Board of Directors on the facility incidents...” Review of a facility document, “Bylaws, Rules and Regulations of the Combined Medical-Dental staffs of St. Luke Community Hospital and Nursing Home,” with a revision date of 2/2023, showed: “ ... Section 14. Emergency Room ... 3. In addition to physician staff, emergency room screening examinations may be performed by a Nurse Practitioner, Physician Assistant or RN. RN’s performing screening examinations must consult the physician prior to determining that no emergency medical condition exists...” 2. Patient #24 presented to the ED on 3/31/23 for right side pain that she had been experiencing for the previous four days. Patient #24 had an elevated heart rate of 114 bpm (normal less than 100), and she had a past medical history significant for recent pregnancy (delivered one month prior), anemia, poor nutrition, and weight loss. Record review of patient #24’s medical chart showed she was not treated or provided discharge instructions related to her tachycardia, and no labs or radiology tests were ordered to determine the cause of the patient’s abdominal pain. Patient #24 did not receive an appropriate MSE to determine if an emergency medical condition existed prior to her discharge from the ED. Review of patient #24’s EMR, dated 3/31/24 showed patient #24 presented to the ED at 5:34 a.m. for rib pain. At 5:38 a.m., patient #24’s triage assessment was completed. Her vital signs were BP 101/64, P 114, R 18, and Spo2 of 98%. Patient #24 received a 20g Peripheral IV at 5:56 a.m. At 6:24 a.m., Staff member K reviewed patient #24’s medical history. Her medical chart did not identify the time she was seen by staff member K. At 6:40 a.m., patient #24 was documented as ready to discharge. Review of patient #24’s ED electronic medical record, dated 3/31/23, showed: “Medical Decision Making Narrative: Patient is a 16-year-old female presenting with right upper quadrant pain. She was dropped off by her aunt and uncle who then left the hospital. Patient is a unaccompanied minor at this time. Her boyfriend tried to contact and get her mother to consent to treat and we currently we are waiting for mom to arrive. Objectively patient appeared nontoxic and in no acute distress. Vital signs were significant for tachycardia heart rate of 114 bpm. She is sitting comfortably in bed at this time waiting her mother’s arrival. Mother did not want to come to the hospital. We did not obtain permission to treat. The patient was discharged with her boyfriend who took her home. I advised the patient that she may take ibuprofen and Tylenol as needed at home and to drink plenty of water. Discussed when she returns home to encourage her mother to take her back to the hospital if she continues to have discomfort or worse symptoms. Patient understood and agreed with this plan.” Review of patient #24’s ED discharge instructions, dated 3/31/23, showed: “Unfortunately we are unable to treat you this morning without parental permission. If symptoms persist please return to the ED with your mother for permission. You may take ibuprofen and Tylenol as needed to help with discomfort. Please drink plenty of water, 1 to 2 L daily. Try to eat small, bland, frequent meals.” During an interview on 4/30/24 at 2:46 p.m., patient #24 stated she went to the ED on 3/31/23, as she had been having stomach pain for two to three days. Patient #24 stated she was seen by the ED physician, but she could not recall what the physician told her, other than the facility had to have parental consent before she could be treated. Patient #24 stated she had recently delivered a baby prior to going to the ED, and the facility was aware of this information. Patient #24 stated the facility tried to reach out to her mother to get consent for her to be treated, but her mother denied coming to the facility to provide consent. Patient #24 stated the facility did not perform any labs, X-rays, or ultrasounds while she was at the ED to determine the cause of her abdominal pain. During an interview on 4/30/24 at 9:10 a.m., staff member C stated she was the manager for the ED. Staff member C stated staff member K saw patient #24 on 3/31/23 and did not provide treatment to the patient because she was a minor and he did not receive parental consent to treat her. Staff member C said patient #24 delivered a viable male on 2/26/24. Staff member C stated someone from the medical records department contacted her when it was discovered during patient #24’s record review that the patient did not need a parent to consent for treatment, as the patient was an emancipated minor. Staff member C stated an email was sent out to all providers on 4/12/23 with a link to education and the state law regarding emancipated minors. Staff member C stated the education was also discussed with the providers during a trauma meeting, which occurred on 4/28/23. During an interview on 5/1/24 at 7:43 a.m., staff member K stated he was the ED physician who saw patient #24 on 3/31/23. Staff member K stated patient #24 was provided a medical screening upon her arrival to the ED. Staff member K stated, “The patient did not have anything life threatening.” Staff member K stated patient #24 did not present with any acute findings and did not appear to be in distress. Staff member K stated he would not have done any further testing or labs for the patient, as the patient had been experiencing her symptoms for several days. Staff member K stated if a minor patient presented to the ED with an emergent condition, he would treat the patient without parental consent. He stated patient #24 did not have an emergent condition or appear to be in distress, and she was discharged and given instructions for return precautions, with instructions to return to the ED if her symptoms changed or worsened. Staff member K said patient #24’s ED visit was discussed in a trauma meeting following the incident, and the medical staff were educated on the conditions required to meet the status of emancipated minors for the state. Staff member K said the medical staff and the emergency department staff were provided further training on the rules and the intent of EMTALA regulations. Review of a facility policy, “Admission to Emergency Department,” with a revision date of 4/2015, showed: “ In compliance with EMTALA regulations, Hospital will provide for appropriate medical screening examinations.... Policy: 1. A medical screening exam must be provided to any individual who presents on hospital property requesting care for an emergency medical condition regardless of diagnosis, financial status, race, color, national origin, or handicap. Record review of facility policy, “Medical Staff Obligations- Emergency Department”, revised 4/2015, showed: “ ...2. Physicians responsible for Emergency Department coverage are required to provide an appropriate medical screening exam for patients presenting with complaint of an emergency medical condition... Record review of a facility provided email, sent by staff member L, dated 4/12/23, showed: “Subject: Consent for minor for Health Services: I have attached the link for [State] Code for the Validity of Consent for Minor for Health Services for you to review. There has been some questions about minors who have had a child and being able to consent for services. Please see 41-1-402 (2)(a) attached...””

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 LSC, 2012 Edition, and those mandatory Codes referenced by that edition. Facilities surveyed under the CAH Centers for Medicare and Medicaid Services Certification Number (CCN) is as follows: 01 Main Hospital 02 2008 Addition The facility was surveyed on 3/18/24, no new construction has occurred since the last survey of the facility on 6/8/16. Building 01, Main Hospital, construction type was found to be Type V (111) and contains three main floor smoke compartments and two in the basement. The 2008 addition includes all departments with the exception of OR, Lab, Cafeteria, and a portion of Materials Management. The facility was surveyed specifically using NFPA 101 2012 Edition, Chapter 19 Existing Health Care Occupancies. The facility had 11 patients/residents at the time of survey. There is a three hour barrier that separates the 2008 Addition from the original CAH building. 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 ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3, 7.2.1.5.10, and 7.2.1.6. Facilities can only lock doors and gates in the case of clinical need such as a special care unit. Findings include: 1. During an observation on 3/18/24 at 12:40 p.m., the marked exit doors going into the OR area were found to be maglocked, with an electronic badge-in device. Egress from the door was with an electronic device using a card to unlock the doors and enter. The system is set up as an “access-controlled” egress special locking arrangement. The motion detector was not a part of the system. Whatever type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress, the facility must then apply all the features the code requires in NFPA 101-2012 Section 7.2.1.6. The locked doors in the lighted path of egress must also unlock and be open to occupants in the event the sprinkler or fire detection systems are activated.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.10.1.2.2.. Findings include: 1. During an observation on 3/18/24 at 12:48 p.m., the lab and phlebotomy area was inspected. There was no exit signage guiding occupants in phlebotomy back out to the egress corridor. there were three doors visible in the area and the egress path was not obvious.”

“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 3/18/24 at 1:45 p.m., the MRI future room was inspected. This is a room where the the MRI machine will be, but for now was being used as a work room and storage area. It is considered a hazardous area. The corridor door to the room was found to not close and latch under the power of the self-closer.”

“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 observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2. Findings Include: 1. During an observation on 3/18/24 at 12:55 p.m., the imaging locker room was inspected. A ceiling mounted light fixture was observed, obstructing a sprinkler head. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head. 2. During an observation on 3/18/24 at 1:10 p.m., resident room 118 was inspected. The curtain rail in the room was found to be obstructing a sprinkler head in the room. The sprinkler was very close to the rail and the rail was lower than the deflector on the head.”

“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, the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 13, 2010 Edition, Section 6.2.7.2. Findings include: 1. During an observation on 3/18/24 at 12:30 p.m., the sleep room was inspected, an escutcheon ring was missing from a sprinkler head in the bathroom.”

“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 maintain corridor doors in accordance with NFPA 101-2012, Section 19.3.6.3.5. Findings include: 1. During an observation on 3/18/24 at 1:39 p.m., the corridor door to the imaging storage room was unable to open fully due to storage behind the door blocking it from opening. Corridor doors must be able to swing open the full length of the swing. 2. During an observation on 3/18/24 at 1:53 p.m., the corridor door to the middle room for materials management was unable to open fully due to storage behind the door blocking it from opening. Corridor doors must be able to swing open the full length of the swing.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 32381 Based on record review, the facility failed to maintain documentation of inspections on all Patient-Care Related Electrical Equipment (PCREE). The deficient practice affected all smoke compartments. Findings include: 1. Review of facility records on 3/18/24 reflected a lack of documentation for the electric beds in the facility having been electrically tested for continuity, resistance, leakage, physical integrity, etc. Actual NFPA Standard: NFPA 99, Health Care Facilities Code (2012) 3.3.137 Patient-Care-Related Electrical Equipment. Electrical equipment appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in a patient care vicinity. 10.3 Testing Requirements - Fixed and Portable. 10.3.1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection. 10.3.2* Resistance. 10.3.2.1 For appliances that are used in the patient care vicinity, the resistance between the appliance chassis, or any exposed conductive surface of the appliance, and the ground pin of the attachment plug shall be less than 0.50 ohm under the following conditions: (1) The cord shall be flexed at its connection to the attachment plug or connector. (2) The cord shall be flexed at its connection to the strain relief on the chassis. 10.3.2.2 The requirement of 10.3.2.1 shall not apply to accessible metal parts that achieve separation from main parts by double insulation or metallic screening or that are unlikely to become energized (e.g., escutcheons or nameplates, small screws). 10.3.3* Leakage Current Tests. 10.3.3.1 General. 10.3.3.1.1 The requirements in 10.3.3.2 through 10.3.3.4 shall apply to all tests. 10.3.3.1.2 Tests shall be performed with the power switch ON and OFF. 10.3.3.2 Resistance Test. The resistance tests of 10.3.3.3 shall be conducted before undertaking any leakage current measurements. 10.3.3.3* Techniques of Measurement. The test shall not be made on the load side of an isolated power system or separable isolation transformer. 10.3.3.4* Leakage Current Limits. The leakage current limits in 10.3.4 and 10.3.5 shall be followed. 10.3.4 Leakage Current - Fixed Equipment. 10.3.4.1 Permanently wired appliances in the patient care vicinity shall be tested prior to installation while the equipment is temporarily insulated from ground. 10.3.4.2 The leakage current flowing through the ground conductor of the power supply connection to ground of permanently wired appliances installed in general or critical care areas shall not exceed 10.0 mA (ac or dc) with all grounds lifted. 10.3.5 Touch Current - Portable Equipment. 10.3.5.1* Touch Current Limits. The touch current for cord connected equipment shall not exceed 100 ?A with the ground wire intact (if a ground wire is provided) with normal polarity and shall not exceed 500 ?A with the ground wire disconnected. 10.3.5.2 If multiple devices are connected together and one power cord supplies power, the leakage current shall be measured as an assembly. 10.3.5.3 When multiple devices are connected together and more than one power cord supplies power, the devices shall be separated into groups according to their power supply cord, and the leakage current shall be measured independently for each group as an assembly. 10.3.5.4 Touch Leakage Test Procedure. Measurements shall be made using the circuit, as illustrated in Figure 10.3.5.4, with the appliance ground broken in two modes of appliance operation as follows: (1) Power plug connected normally with the appliance on (2) Power plug connected normally with the appliance off (if equipped with an on/off switch) 10.3.5.4.1 If the appliance has fixed redundant grounding (e.g., permanently fastened to the grounding system), the touch leakage current test shall be conducted with the redundant grounding intact. 10.3.5.4.2 Test shall be made with Switch A in Figure 10.3.5.4 closed. 10.3.6* Lead Leakage Current Tests and Limits - Portable Equipment. 10.3.6.1 The leakage current between all patient leads connected together and ground shall be measured with the power plug connected normally and the device on. 10.3.6.2 An acceptable test configuration shall be as illustrated in Figure 10.3.5.4. 10.3.6.3 The leakage current shall not exceed 100 ?A for ground wire closed and 500 ?A ac for ground wire open. 10.5.2.1 Testing Intervals. 10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. 10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety. 10.5.2.5* System Demonstration. Any system consisting of several electric appliances shall be demonstrated to comply with this code as a complete system. 10.5.3 Servicing and Maintenance of Equipment. 10.5.3.1 The manufacturer of the appliance shall furnish documents containing at least a technical description, instructions for use, and a means of contacting the manufacturer. 10.5.3.1.1 The documents specified in 10.5.3.1 shall include the following, where applicable: (1) Illustrations that show the location of controls (2) Explanation of the function of each control (3) Illustrations of proper connection to the patient or other equipment, or both (4) Step-by-step procedures for testing and proper use of the appliance (5) Safety considerations in use and servicing of the appliance (6) Precautions to be taken if the appliance is used on a patient simultaneously with other electric appliances (7) Schematics, wiring diagrams, mechanical layouts, parts lists, and other pertinent data for the appliance (8) Instructions for cleaning, disinfection, or sterilization (9) Utility supply requirements (electrical, gas, ventilation, heating, cooling, and so forth) (10) Explanation of figures, symbols, and abbreviations on the appliance (11) Technical performance specifications (12) Instructions for unpacking, inspection, installation, adjustment, and alignment (13) Preventive and corrective maintenance and repair procedures 10.5.3.1.2 Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. 10.5.6 Record Keeping - Patient Care Appliances. 10.5.6.1 Instruction Manuals. 10.5.6.1.1 A permanent file of instruction and maintenance manuals shall be maintained and be accessible. 10.5.6.1.2 The file of manuals shall be in the custody of the engineering group responsible for the maintenance of the appliance. 10.5.6.1.3 Duplicate instruction and maintenance manuals shall be available to the user. 10.5.6.1.4 Any safety labels and condensed operating instructions on an appliance shall be maintained in legible condition. 10.5.6.2* Documentation. 10.5.6.2.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 10.5.6.2.2 At a minimum, the record shall contain all of the following: (1) Date (2) Unique identification of the equipment tested (3) Indication of which items have met or have failed to meet the performance requirements of 10.5.6.2 10.5.6.3 Test Logs. A log of test results and repairs shall be maintained and kept for a period of time in accordance with a health care facility’s record retention policy. 10.5.8 Qualification and Training of Personnel. 10.5.8.1* Personnel concerned for the application or maintenance of electric appliances shall be trained on the risks associated with their use. 10.5.8.1.1 The health care facilities shall provide programs of continuing education for its personnel. 10.5.8.1.2 Continuing education programs shall include periodic review of manufacturers’ safety guidelines and usage requirements for electrosurgical units and similar appliances. 10.5.8.2 Personnel involved in the use of energy-delivering devices including, but not limited to, electrosurgical, surgical laser, and fiberoptic devices shall receive periodic training in fire suppression. 10.5.8.3 Equipment shall be serviced by qualified personnel only.”

“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: 44769 Based on observation, interview and record review, the facility failed to follow their established policies and procedures; and failed to perform timely preventive maintenance for two “Vapotherm high-flow respiratory support systems.” Findings include: During an observation and interview on 2/13/24 at 1:40 p.m., a Vapotherm, model, “Precision Flow Plus,” serial number PFPC00048536-E, was noted to have a preventive maintenance sticker reflecting an inspection on 2/2021, and a next due inspection of 2/2022. Staff member P was unable to find a current inspection sticker and said he did not know if the machine had had a more recent preventative maintenance. During an observation and interview on 2/13/24 at 1:44 p.m., a Vapotherm, model, “Precision Flow Plus,” serial number PFPC00042152-E, was noted to not have a preventive maintenance sticker. Staff member P said he was unaware of when or if the machine had had any preventative maintenance. During an interview on 2/15/24 at 9:25 a.m., staff member Q stated there were no current preventative maintenance records for the two Vapotherm machines. During an interview on 2/15/24 at 9:55 a.m., staff member Q stated the machines were purchased in 2020 and stated, “I don’t think there has been a pm since they were purchased.” Staff member Q stated each department head makes sure the machine maintenance was done on their department’s equipment. Staff member Q stated, “I don’t think [staff member P] knows about the service contracts, he’s new.” A review of a facility policy titled, “Plant/Maintenance,” with a revised date of 5/6/20, showed: -“Purpose: -To ensure that all essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition. -Policy: ... -... Preventive maintenance: The preventive maintenance program is provided by the maintenance department either directly or through the use of a contract service or the equipment vendor. Schedules and records are maintained. ...””

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 41951 Based on observation, interview, and record review, the facility failed to ensure the medication room, located in the oncology infusion center, was locked at all times. Findings include: During an observation on 2/13/24 at 9:38 a.m., staff member I was seated next to an infusion patient, with her back to the entrance of the oncology infusion center entrance doors, which were open. During an observation and interview on 2/13/24 at 9:38 a.m., staff member E opened the medication room door in the oncology infusion center, and entered the room. The medication room door was not locked to restrict unauthorized personnel. Staff member E stated the door to the medication room was not kept locked when nurses were present in the oncology infusion center. During an observation on 2/13/24 at 9:45 a.m., the following medications were observed on an open shelf in the oncology infusion medication room: -Five boxes of Palonosetron (a medication used to treat nausea and vomiting) 0.25 mg/5ml; -Three boxes of Abraxane (a chemotherapy medication) 100 mg vial; -One box of Docetaxel (a chemotherapy medication) 160 mg/8 ml; and -One box of Gemcitabine (a chemotherapy medication) 20 mg vial. During an observation on 2/13/24 at 9:45 a.m., the oncology infusion medication room refrigerator was inspected. Multiple boxes/containers of chemotherapy medications were observed being stored in the refrigerator. During an interview on 2/13/24 at 9:55 a.m., staff member I stated the door to the pharmacy/medication room in the oncology infusion center was always unlocked during the day when the center was open, Monday - Friday, 7:00 a.m. - 3:30 p.m. Review of the facility’s policy titled, Antineoplastic Medications, last revised 4/19/23, showed: - ... “12. When the OCP (Oncology Center Pharmacy) is not in use, access shall be restricted via locking the outer door with only pharmacy personnel and the infusion nurse having direct access. ...””