Mineral Community Hospital

“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 05/28/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, 2012 Edition, Chapter 18 New Healthcare Occupancies and those mandatory Codes referenced by that edition. The building construction type was found to be Type II (111). New construction has occurred since the last survey of the facility on 06/30/2021. The facility completed an addition, adding a reception hallway which connected a business occupancy to the already existing healthcare occupancy. There was a two-hour wall present, therefore the business occupancy was not surveyed. The facility is licensed for 25 beds with a census of 11 patients at the time of this survey. 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 05/28/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, 2012 Edition, Chapter 19 Existing Healthcare Occupancies and those mandatory Codes referenced by that edition. The building construction type was found to be Type II (111). New construction has occurred since the last survey of the facility on 06/30/2021. The facility completed an addition, adding a reception hallway which connected a business occupancy to the already existing healthcare occupancy. There was a two-hour wall present, therefore the business occupancy was not surveyed. The facility is licensed for 25 beds with a census of 11 patients at the time of this survey. These requirements were not met as evidenced by the following deficiencies:”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 40068 Based on observation the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2. This deficiency affected 1 out of 2 smoke compartments in the facility. Findings include: During an observation on 5/28/24 at 12:10 p.m., the employee restroom was inspected. The door was fitted with a lock that required two motions to unlock.”

“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: 40068 Based on an observation the facility failed to provide exit signage in accordance with NFPA 101-2012, Section 7.10.2.1. This deficiency affects 1 of 2 smoke compartments. Findings Include: During an observation on 5/28/24 at 12:35 p.m., the ER hallway was inspected. A directional exit sign was not present in the hallway directing occupants which direction to travel to the nearest exit.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to ensure an alcohol-based hand rub (ABHR) dispenser was not mounted within 1 inch of an ignition source in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8 b). This deficiency affects 1 out of 2 smoke compartments in the facility. Findings include: During an observation on 5/28/24 at 11:41 a.m., the kitchen was inspected. A hand sanitizer pump was installed within one inch of an ignition source.”

“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: 40068 Based on observation the facility did not have fire suppression sprinklers serving all areas of the facility per NFPA 101, 2012 Edition, Section 19.1.6.1 and Table 19.1.6.1. This deficiency affected 1 out of two smoke compartments in the facility. Findings include: During an observation on 5/28/24 at 11:46 a.m. the east entrance canopy was inspected. There was a canopy outside the east entrance that did not have any suppression. Type II (111) building construction needs to have fire suppression throughout.”

“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 and record review the facility failed to: a) complete monthly standpipe gauge readings for the wet system per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1., b) 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)., and c) maintain escutcheon plates around sprinkler heads in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 6.2.7.1. This deficiency affects all residents and staff at the facility. Findings include: 1.Review of the facility’s maintenance records showed monthly documentation of the wet sprinkler system pressure gauges was not being documented. 2. During an observation on 5/28/24 at 11:32 a.m., the back-up boiler room was inspected. A ceiling tile was sagging creating gapping around the ceiling. 3. During an observation on 5/28/24 at 12:11 p.m. the PT entrance hall was inspected. There were three perforations in the ceiling tiles. 4. During an observation on 5/28/24 at 12:46 p.m. the server room was inspected. There was a broken ceiling tile. 5. During an observation on 5/28/24 at 12:09 p.m. room 104-A was inspected. Two missing escutcheon rings were missing on sprinkler heads in the room. 6. During an observation on 5/28/24 at 12:45 p.m. the doctor’s office was inspected. There was a missing escutcheon ring on a sprinkler head in the room.”

“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 record review the facility failed to complete monthly standpipe gauge readings for the wet system per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1., This deficiency affects all residents and staff at the facility. Findings include: Review of the facility’s maintenance records showed monthly documentation of the wet sprinkler system pressure gauges was not being documented.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 40068 Based on observation and interview the facility failed to install portable fire extinguishers in accordance with NFPA 101 Life Safety Code 2012 Edition, Sections 19.3.5.12, and NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Sections 6.1.3.4 and 6.1.3.8.1. This deficiency affects all residents and staff of the facility. Findings include: During an observation on 5/28/24 at 11:38 a.m. the generator room was inspected. There was a fire extinguisher mounted 5 feet 7 inches off the ground. During an interview on 5/28/24 at 11:39 a.m., staff member C stated most of the fire extinguishers in the building will be mounted too high. Staff member C stated he will have to move them all to the proper height. During an observation on 5/28/24 at 11:43 a.m. the kitchen was inspected. There were two fire extinguishers mounted more than 5 feet off the ground. During an observation on 5/28/24 at 12:43 p.m., the surgery suite was inspected. A fire extinguisher was mounted more then 5 feet off the ground. During an observation on 5/28/24 at 12:47 p.m., the server room was inspected. A fire extinguisher was free standing on the floor of the room. During an observation on 5/28/24 at 12:52 p.m., the south entrance was inspected. A fire extinguisher was mounted more then 5 feet off the ground.”

“Corridor - Doors CFR(s): NFPA 101 Doors protecting corridor openings shall be constructed to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have self-latching and 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 18.3.6.3.6 are permitted. 18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatic closing devices, etc. This Standard is not met as evidenced by: 40068 Based on observation the facility failed to maintain corridor door openings in accordance with NFPA 101, 2012 Edition, Section 18.3.6.3.10. This deficiency affects all smoke compartments in the building. Findings include: During an observation on 5/28/24 at 5:37 p.m. the dictation room was inspected. The corridor door was held open by a rubber wedge. During an observation on 5/28/24 at 5:38 p.m. the isolation room was inspected. The corridor door was held open by a rubber wedge.”

“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 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: 1.During a review of facility fire drills on 5/28/24 it was determined the facility was missing the following fire drills: The evening shift of the second quarter of 2023 (April-June) The evening shift of the fourth quarter of 2023 (October - December) The evening shift of the first quarter of 2024 (January - March)”

“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 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: 1.During a review of facility fire drills on 5/28/24 it was determined the facility was missing the following fire drills: The evening shift of the second quarter of 2023 (April-June) The evening shift of the fourth quarter of 2023 (October - December) The evening shift of the first quarter of 2024 (January - March)”

“Soiled Linen and Trash Containers CFR(s): NFPA 101 Soiled Linen and Trash Containers Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended. Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent. 18.7.5.7, 19.7.5.7 This Standard is not met as evidenced by: 40068 Based on observation and interview the facility failed to keep soiled linen receptacles greater than 32 gallons in an area protected as hazardous in accordance with NFPA 101, 2012 Edition, Section 19.7.5.7.1. This deficiency affects 1 of 2 smoke compartments in the facility. Findings include: During an observation on 5/28/24 at 11:54 a.m. the 200 hallway was inspected. There was a 50-gallon soiled linen container in the hallway. During an interview on 5/28/24 at 11:55 a.m. staff member C stated there will be multiple containers like that in the hallway. Staff member C stated they are used for trash or soiled linen. During an observation on 5/28/24 at 12:01 p.m. the hallway by room 202 was inspected. There was a 50-gallon soiled linen container in the hallway.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 40068 Based on record review and interview the facility failed to ensure piped oxygen shutoff valves were properly labeled in accordance with NFPA 99 Healthcare Facilities Code 2012 Edition, Section 5.3.11.2. This deficiency affected 1 out of 2 smoke compartments in the facility. Findings include: During an observation on 5/28/24 at 12:36 p.m., the ER hallway was inspected. There was a medical gas shut off valve located on the wall. There was no label on the shut off valve indicating the room(s) or area(s) served. During an interview on 5/28/24 at 12:37 p.m., staff member C stated that piped oxygen was being used and was not sure what areas the shut off valve served.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 40068 Based on an observation the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d). This deficiency affects 1 out of 2 smoke compartments in the facility. Findings include: During an observation on 5/28/24 at 12:47 p.m., the server room was inspected. There was storage located in front of the electrical panel.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B). This deficiency affected 1 out of 2 smoke compartments. Findings include: During an observation on 5/28/24 at 12:46 p.m. the server room was inspected. Two outlets were missing cover plates.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to maintain the proper signage for the storage room for oxygen cylinders in accordance with NFPA 99, 2012 Edition, Section 5.1.3.1.9. This deficiency affects 1 out of 2 smoke compartments. Findings include: During an observation on 5/28/24 at 12:53 p.m., the oxygen storage room was observed. There was signage located on the door, but it was illegible. The signage was painted over.”

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 44770 Based on observation, interview, and record review, the facility failed to document patient Advance Directives for 5 (#s 6, 7, 8, 9, and 10) of 10 sampled ED (emergency department) patients. In the event of an emergency medical situation, this deficiency could cause the providers to be unaware of a patient’s wishes. Findings include: During record review on 5/7/24, patients # 6, 7, 8, 9, and 10’s medical records did not show an advance directive was entered in the patient’s medical record. The Emergency Department documentation did not show the patients were asked if they had an Advance Directive. During an observation and interview on 5/8/24 at 12:10 p.m., staff member B was asked to locate the Advance Directives in the medical records for patients #6, 7, 8, 9, and 10. Staff member B was unable to locate the Advance Directives and was unable to locate documentation indicating the patients were asked if they had Advance Directives. Staff member B stated the EMR (electronic medical record) used to have a hard stop written in the system that required staff to ask patient’s if they had an Advance Directive. However, after an update the hard stop disappeared. Staff member B said staff should be asking patients if they have an Advance Directive, and they should be documenting the answer. After being unable to find the Advance Directive in the EMR staff member B stated the nurses must not be answering the question or documenting it since there is no longer a hard stop in the system. Review of a facility Policy titled, POLST/Advance Directives, dated 1/9/24, showed: “...A patient/resident who has the capacity to make a health care decision and who withholds consent to treatment or makes an explicit refusal of treatment either directly or through an advance directive, may not be treated against his/her wishes...””

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 44769 Based on review of facility video surveillance footage, interview, and record review, the facility failed to follow a patient’s comprehensive care plan for 1 (#11) of 10 sampled swing bed patients. This deficient practice resulted in the patient sustaining a fall which resulted in a hip fracture. Findings include: Review of facility video surveillance footage dated 3/13/24 at 7:03 p.m., showed patient #11 was sitting in her wheelchair in the day room. Patient #11 rose from her wheelchair and attempted to use the wheelchair to assist her with ambulating. Patient #11 took three steps and fell on her back. Patient #11 was observed hitting her head on the floor. Once on the floor, the patient used her right arm to hold her head and continued to lie on the floor until a staff member entered the room; one minute after the patient sustained the fall. During an interview on 5/7/24 at 5:13 p.m., staff member Q stated he was one of two CNA’s who worked the night shift on the swing bed unit on 3/13/24. Staff member Q stated he was in the swing bed day room with several patient’s but was called to the ER prior to patient #11’s fall and was not on the swing bed side of the hospital when patient #11 fell. Staff member Q stated a chair alarm was used on patient #11’s wheelchair, but he did not know if it was on her chair the evening of 3/13/24. During an interview on 5/28/24 at 11:05 a.m., staff member I stated patient #11 was in the day room of the facility on 3/13/24 and sustained a fall. Staff member I stated patient #11 was sitting in her wheelchair and stood up and proceeded to use her wheelchair to assist her with walking. While patient #11 was attempting to ambulate, she fell. Staff member I stated this was the first fall for patient #11 since her admission to the facility. Staff member I stated patient #11’s wheelchair did not have an alarm on it at the time of her fall. Staff member I stated patient #11 was a high fall risk and had care plan interventions in place to always have a wheelchair alarm on while she was in her wheelchair. Staff member I stated patient #11 was assessed after her fall and transported to the ED for further evaluation. Staff member I stated patient #11 sustained a hip fracture and was transferred to another hospital. Review patient #11’s EHR, with a swing-bed admit date of 2/22/24, showed the patient had diagnoses which included: Altered mental status, unspecified, unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of patient #11’s care plan, with an initiated date of 2/23/24, showed: “Plan: Fall Prevention/Management... Phase: Fall Prevention... Note: bed and chair alarm in place at all times (Charted at 3/11/2024, 8:07 A.M. by [staff member T]). Record review of patient #11’s EHR showed the patient had a Morse fall score of 80, which was recorded on 3/11/24 at 6:15 p.m., by staff member R (a Morse fall score of 45 or greater is considered a high falls risk for falls). Record review of patient #11’s admission paperwork, dated 2/22/24, completed by staff member S, showed: “84 yo female admitted for altered mental status, delirium with dementia...At high risk for falls ...Multiple bruises on extremities consistent with history of multiple cushioned fall...does require 1:1 Nursing at times.” [sic] Record review of “Discharge Documentation” for patient #11, dated 3/13/24, showed: “Physical Exam...I was called to the day room and notified that [patient #11] had fallen. Fall was initially unwitnessed, but staff was able to view the fall on video. It appears that [patient #11] tried to walk using her wheelchair as a walker; the wheelchair seemed to get a bit ahead of her and she fell onto her left hip...Staff notes that her left leg is shortened, tender, and externally rotated at the hip concerning for a hip fx ... Exam...Extremities; left leg is externally rotated at the hip; appears shortened...”[sic] Review of patient #11’s “Diagnostic Radiology” report, dated 3/13/2024 at 7:48 p.m., showed: “...Report There is a fracture of the left femoral neck with slight varus angulation. Status post right hip arthroplasty. Degenerative change in the lower lumbar spine. IMPRESSION: 1. Fracture of the left femoral neck...”[sic] A review of a facility policy, titled, “Comprehensive Assessment, Comprehensive Care Plan, and Discharging Planning Policy,” showed: “PURPOSE: Comprehensive assessment, comprehensive care plan, and discharge planning policy of Mineral Community Hospital. All patients admitted to the Swing Bed Unit shall receive a comprehensive, accurate, standardized reproducible assessment of each resident’s functional capacity by a qualified individual so that a plan of care, along with discharge planning can be developed to best meet the needs of patients. The assessment of the care or treatment needs of the patients will be ongoing throughout the patient’s hospital stay... A complete assessment shall include:... C. Cognitive patterns... H. Physical functioning and structural problems... O. Special treatments and procedures...””