Logan Health - Whitefish

“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 review, and policy review, the facility failed to comply with the conditions of participation outlined in §489.24: (refer to Appendix V). The facility failed to provide a MSE (medical screening examination) by a QMP (qualified medical provider) within the capability of the hospital’s ED (emergency department), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists for 1 (#15); failed to provide stabilizing treatment; and the facility failed to provide an appropriate transfer for 1 (#15) of 20 sampled patients who presented to the ED for emergency care. Findings include: Review of a facility policy, “Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed: “ ...Medical Screening Examination 1. When an individual comes to the hospital Campus requesting examination or treatment for an EMC, or who appears to a reasonable observer to need medical treatment, an MSE will be performed by an individual qualified to perform such an examination, to determine whether an EMC exists, or, with respect to a pregnant woman having contractions, whether the woman is in labor. ...” “ ...2. A transfer will be an appropriate transfer if: ...B. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment; ...Additional Transfer-Related Situations ...4. Transfers for High Risk Deliveries. A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer even if a transfer agreement is in place. In addition, a provider certification that the benefits of transfer outweigh the risks of transfer is required for the transfer of a woman in labor. -Patient #15 presented to the OB department with premature rupture of membranes at 34 weeks gestation. The patient was not provided a MSE by a QMP. [See A-2406] -Patient #15 was sent to another hospital for a higher level of care. The facility failed to notify the receiving hospital of the transfer and ensure the hospital had qualified personnel and space available to provide care for the patient. [See A-2409]”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 45448 Based on observation, interview and policy review, the facility failed to post signs specifying the rights of individuals to receive an examination and treatment for emergency medical conditions, and the rights of women in labor, in a conspicuous area to be noticed by all individuals entering and receiving care in the ED (emergency department) and the OB (obstetrics department). Findings include: During an observation and interview on 6/17/25 at 7:48 a.m., the ED waiting room was inspected. A single sign was posted with information on patient EMTALA rights. The sign was written in English and lacked information regarding filing a complaint with CMS. Observations within the ED hallways and examination rooms showed the areas lacked EMTALA signage. Staff member G stated the facility had placed an order to replace the existing signage. Staff member G stated the new signage would be available in English and in Spanish and would conform to the facility signage policy. Staff member G stated she was not aware of the requirement for the EMTALA signage to be posted in patient treatment areas. During an observation and interview on 6/17/25 at 8:04 a.m., the obstetric waiting area was observed. The waiting area did not have any posted signage regarding patient EMTALA rights. Observations of the obstetric department, including labor/delivery rooms, triage room, and hallways, revealed the areas did not have signage regarding patient EMTALA rights. Staff member F stated EMTALA signs were posted at each of the hospital entries; on the wall in the vestibule, and between the two sliding glass entry doors. Staff member F said patients entering the facility for OB care and treatment would register at the registration desk at the entry of the OB department and would wait in the OB waiting room or enter the OB department for treatment. Staff member F said she was not aware EMTALA signage was required to be posted in patient waiting areas and patient treatment areas. Review of a facility policy, “Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed: “ ...Medical Screening Examination 3. Signs are posted in [facility name] Eds specifying the rights of individuals with an EMC and women in labor who come to a [facility name] ED for health care services, and the signs indicate that the hospital participates in the Medicaid and Medicare programs. ...””

“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 policy review, the facility failed to provide a MSE (medical screening examination) by a QMP (qualified medical provider) within the capability of the hospital’s ED (emergency department), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists for 1 (#15) of 20 sampled patients. Findings include: Review of patient #15’s electronic medical record, dated 4/26/25, showed: - 00:22 a.m., patient #15 arrived at the facility with a complaint of premature rupture of membranes at 34 weeks 2 days - 00:30 a.m., patient #15 was assessed by staff member E. Testing for ruptured fetal membranes (ROM), a vaginal examination with results of 2cm diameter dilation and 90% effacement (determines readiness for labor and delivery), soft cervix, no vaginal bleeding. - 00:37 a.m., staff member E notified the provider (staff member H) of examination findings. Communication comments showed: “[Staff member H] stated if patient is stable with no threat of labor, she can be given the option to be discharged and drive herself to [hospital B] or go via ambulance.” - 00:50 a.m., Communication comments showed: “Called provider back, I asked her to come in and evaluate patient to deem her stable to ride via car. [Staff member H] stated that if patient is 2cm/90% with reactive NST (measures baby’s heart rate response to movement) and no threat of labor she is considered stable and would not need to come in and evaluate her in person. - 1:07 a.m., patient #15 discharged with instructions to head to [hospital B] immediately. No documentation was found in the EMR for staff member H. Patient #15 arrived at [hospital b] at 1:36 a.m. During an interview on 6/23/25 at 12:34 p.m., patient #15 said on 4/26/25 her water had broken, and she called her physician’s office. Patient #15 said she had spoken to the physician on call, and she was instructed to go to the ED to be evaluated. Patient #15 stated she was concerned because she knew the facility could not care for a baby delivered at 34 weeks and she would have to be transferred to another facility. Patient #15 said when she arrived at the ED, the OB nurse checked and confirmed her water had broken. She stated she was not seen by a provider. Patient #15 stated the OB nurse discharged her and instructed her and her husband to go directly to [hospital B], which was 12 miles away. During an interview on 6/18/25 at 7:47 a.m., staff member E said patient #15 arrived at the ED for a complaint of ruptured membranes. Staff member E said the standard practice for a possible rupture of membranes was to do a ROM+ test (Rupture of Membranes test to check for amniotic fluid) for verification of membrane rupture, and to perform a NST (prenatal test that monitors a baby’s heart rate and how it reacts to movement during pregnancy) to determine fetal wellbeing and if the patient was having contractions. Staff member E stated a nurse would then notify the physician of the findings. Staff member E stated she performed a ROM+ test and determined patient #15 was positive for ruptured membranes. Staff member E stated she performed an NST, which was reactive, and performed a vaginal examination. Staff member E stated she did not believe patient #15 was having contractions. Staff member E stated she informed staff member H of her findings and staff member H made the determination to send patient #15 to [hospital B] via her personal vehicle for a higher level of care. Staff member E stated she consulted another staff member and staff member D, the house coordinator, and then made a second phone call to staff member H. Staff member E stated she asked staff member H to come in and evaluate patient #15 to determine if she was stable enough to go to [hospital B] via personal vehicle. Staff member E stated staff member H stated if all the information she was reporting was correct, patient #15 was not in active labor and was stable enough she could be discharged and go to [hospital B] via private vehicle. Staff member E said she discharged patient #15 via private vehicle to go directly to [hospital B]. During an interview on 6/18/25 at 9:05 a.m., staff member D said she told staff member E the doctor should come in and evaluate the patient to determine if she is stable or unstable and able to go to another facility via private vehicle. During an interview on 6/25/25 at 8:42 a.m., staff member H said she had received a phone call from patient #15 stating she thought she had “broke her water”, and she was 34 weeks gestation. Staff member H stated she instructed patient #15 to go to [hospital B] for evaluation. Staff member H stated she explained to patient #15 that [facility name] was not equipped to care for a 34-week infant. Staff member H said she then received a call from the OB nurse stating patient #15 had arrived at the ED and she was proven ruptured, and she was on the monitor (device to measure contractions and fetal heart rate) and not contracting. Staff member H said patient #15 was stable and could go via private vehicle to [hospital B]. Staff member H stated she did not remember staff member E asking her to come and evaluate patient #15 to determine if she was stable. Staff member H stated she was not aware the nurses at the ED were not trained or able to do a MSE. Staff member H said she was not provided with education before or after the incident on the EMTALA requirements for the facility. During an interview on 6/25/25 at 12:33 p.m., staff member I said she was the Medical Director for the Birth Center at the facility. Staff member I stated that any patient coming to the facility in preterm labor requires a provider to come in and do an evaluation at the bedside and initiate the transfer to another facility through the call center. During an interview on 6/25/25 at 11:24 a.m., staff member F stated if a patient was to arrive at the ED with a rupture of membranes, earlier than 34 weeks and not in labor, the provider would come in to evaluate the patient’s stability and arrange for transport to another facility for a higher acuity of care. Staff member F said nursing staff were currently not designated as QMP’s and unable to perform a MSE. During an interview on 6/26/25 at 10:33 a.m., staff member A said the facility did not have a policy that contains the educational requirements for a nurse to be trained to perform an MSE within the OB setting. Review of a facility policy, “Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed: “ ...Medical Screening Examination 1. When an individual comes to the hospital Campus requesting examination or treatment for an EMC, or who appears to a reasonable observer to need medical treatment, an MSE will be performed by an individual qualified to perform such an examination, to determine whether an EMC exists, or, with respect to a pregnant woman having contractions, whether the woman is in labor. ...Definitions ...7. “Qualified Medical Person (QMP)” may include licensed or certified clinical social workers, registered nurses, physician assistants, psychologists, and other professionals delineated as such in governing by-laws of the scope of the EMC is within the individual’s scope of practice. ...” Review of a the facility “Critical Access Hospitals Medical Staff Credentials Policy,” with a revision date of 1/2025, showed: “...Qualified Medical Personnel (QMP) is a Physicaian or Advanced Practice Professional who is qualified to perform a Medical Screening Examination (“MSE”) to determine if a patient has an Emergency Medical Condition (“EMC”) as defined in the Emergency Medical Treatment and Active Labor Act (“EMTALA”). ...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 45448 Based on interview and record review, the facility failed to provide stabilizing treatment to a patient who presented with signs of premature rupture of membranes for 1(#15) of 20 sampled patients. Findings include: Review of patient #15’s electronic medical record, dated 4/26/25, showed: - 00:22 a.m., patient #15 arrived at the facility with a complaint of premature rupture of membranes at 34 weeks 2 days - 00:30 a.m., patient #15 was assessed by staff member E. Premature ruptured of membranes (PROM) was confirmed. - 00:37 a.m., staff member E notified the provider (staff member H) of examination findings. Communication comments showed: “[Staff member H] stated if patient is stable with no threat of labor, she can be given the option to be discharged and drive herself to [hospital B] or go via ambulance.” - 00:50 a.m., Communication comments showed: “Called provider back, I asked her to come in and evaluate patient to deem her stable to ride via car. [Staff member H] stated that if patient is 2cm/90% with reactive NST and no threat of labor she is considered stable and would not need to come in and evaluate her in person.” - 1:01 a.m., Communication comments showed: “patient given option to be discharged and drive via private car to [hospital B] or take an ambulance, ...Discharge orders placed.” - 1:07 a.m., patient #15 discharged with instructions to head to [hospital B] immediately. During an interview on 6/23/25 at 12:34 p.m., patient #15 said on 4/26/25 her water had broken, and she called her physician’s office. Patient #15 said she had spoken to the physician on call, and she was instructed to go to the ED to be evaluated. Patient #15 said when she arrived at the ED, the OB nurse checked and confirmed her water had broken. Patient #15 said the facility did not start an IV or give her any medication. She stated she was not seen by a provider. Patient #15 stated the OB nurse discharged her and instructed her and her husband to go directly to [hospital B], which was 12 miles away. Patient #15 stated she was having some cramping following her vaginal examination. During an interview on 6/18/25 at 7:47 a.m., staff member E said patient #15 arrived at the ED for a complaint of ruptured membranes. Staff member E stated she performed a ROM+ test and determined patient #15 was positive for ruptured membranes. Staff member E stated she performed an NST (prenatal test that monitors a baby’s heart rate and how it reacts to movement during pregnancy), which was reactive, and performed a vaginal examination. Staff member E stated she did not believe patient #15 was having contractions. Staff member E stated she informed staff member H of her findings and staff member H made the determination to send patient #15 to [hospital B] via her personal vehicle for a higher level of care. Staff member E stated she made a second phone call to staff member H. Staff member E stated she asked staff member H to come in and evaluate patient #15 to determine if she was stable enough to go to [hospital B] via personal vehicle. Staff member E stated staff member H stated if all the information she was reporting was correct, patient #15 was not in active labor and was stable enough she could be discharged and go to [hospital B] via private vehicle. Staff member E said she discharged patient #15 via private vehicle to go directly to [hospital B]. During an interview on 6/18/25 at 9:05 a.m., staff member D said she told staff member E the doctor should come in and evaluate the patient to determine if she is stable or unstable and able to go to another facility via private vehicle. During an interview on 6/25/25 at 8:42 a.m., staff member H said she had received a phone call from patient #15 stating she thought she had “broke her water”, and she was 34 weeks gestation. Staff member H stated she instructed patient #15 to go to [hospital B] for evaluation. Staff member H said she then received a call from the OB nurse stating patient #15 had arrived at the ED and she was proven ruptured, and she was on the monitor (device to measure contractions and fetal heart rate and not contracting. Staff member H said patient #15 was stable and could go via private vehicle to [hospital B]. During an interview on 6/25/25 at 11:24 a.m., staff member F, Director of the Birth Center, stated if a patient was to arrive with a rupture of membranes, earlier than 34 weeks and not in labor, the provider would come in to evaluate the patient’s stability and arrange for transport to another facility for a higher acuity of care. Review of patient #15’s EMR showed there was no documentation of an evaluation for stability for transfer or documentation of stabilizing treatment provided. Review of a facility policy, “Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed: “...4. Transfers for High Risk Deliveries. A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer even if a transfer agreement is in place. ...””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45448 Based on interviews, record review and policy review, the facility failed to provide an appropriate transfer for 1 (#15) of 20 sampled patients who presented to the ED for emergency care. Findings include: Review of patient #15’s electronic medical record, dated 4/26/25, showed: - 00:22 a.m., patient #15 arrived at the facility with a complaint of premature rupture of membranes at 34 weeks 2 days - 00:30 a.m., patient #15 was assessed by staff member E. Testing for ruptured fetal membranes (ROM), a vaginal examination with results of 2cm diameter dilation and 90% effacement, soft cervix, no vaginal bleeding. - 00:37 a.m., staff member E notified the provider (staff member H) of examination findings. Communication comments showed: “[Staff member H] stated if patient is stable with no threat of labor, she can be given the option to be discharged and drive herself to [hospital B] or go via ambulance.” - 00:50 a.m., Communication comments showed: “Called provider back, I asked her to come in and evaluate patient to deem her stable to ride via car. [Staff member H] stated that if patient is 2cm/90% with reactive NST and no threat of labor she is considered stable and would not need to come in and evaluate her in person. She said the patient could speak to her on the phone if she had any questions.” - 1:01 a.m., Communication comments showed: “Patient given option to be discharged and drive via private care to [hospital B] or take an ambulance, ...Discharge orders placed.” - 1:07 a.m., patient #15 discharged with instructions to head to [hospital B] immediately. Review of patient #15’s EMR showed there was no documentation of an evaluation for stability for transfer, no documentation of transfer paperwork provided, no documentation to indicate [hospital B] was contacted for verification of qualified personnel to care for the mother and baby, or verification space was available within the NICU to provide care for a 34-week gestation baby. Review of patient #15’s electronic medical record for [hospital B], dated 4/26/25, showed: - 1:30 a.m., patient #15 arrived in Labor & Delivery Unit (L&D) - History of present illness, showed: “ ...[Patient #15] presented to [hospital A] where she was evaluated with a positive ROM+ test and cervix was noted to be 2cm and 90% effaced. She was not thought to be in labor at [hospital A]. She was then discharged ...and instructed to come to [hospital B] via private vehicle for management of PPROM. She is having intermittent cramping that seems like contractions, but not regular; ctx more significant after cervical exam. ...” - OB delivery note showed: At 9:35 a.m. a baby was delivered and required transfer to a NICU at [hospital C] as the NICU at [hospital B] was on diversion. During an interview on 6/23/25 at 12:34 p.m., patient #15 said on 4/26/25 her water had broken, and she called her physician’s office. Patient #15 said she had spoken to the physician on call, and she was to go to the ED to be evaluated. She said she was concerned because she knew the facility could not care for a baby delivered at 34 weeks and they would have to be transferred to a NICU somewhere. Patient #15 said she was discharged from the ED and instructed to go to [hospital B] immediately. Patient #15 said she and her husband were informed when they arrived at [hospital B] the NICU was full and on divert and they would not be able to keep the baby at the facility. Patient #15 said she elected to stay at [hospital B] and see if labor could be stalled. Once the baby was delivered, patient #15 stated the baby was flown to [hospital C] for NICU care for respiratory distress. During an interview on 6/18/25 at 7:47 a.m., staff member E said patient #15 came into the facility for a complaint of ruptured membranes. Staff member E stated she performed a ROM+ test and determined patient #15 was positive for ruptured membranes. Staff member E performed a NST, which was reactive, and performed a vaginal examination. Staff member E stated she reported the findings to staff member H. Staff member E stated she did not believe patient #15 was having contractions. Staff member E stated staff member H made the determination to send patient #15 to [hospital B] via personal vehicle for a higher level of care. Staff member E stated she informed staff member H she was not comfortable with discharging the patient to drive via personal vehicle. Staff member E stated she consulted another staff member and the staff member D, the house coordinator. She stated she informed staff member D, patient #15 had a preterm rupture of membranes but was not in labor and she did not think it was appropriate to discharge the patient to drive to [hospital B] via private vehicle. Staff member E stated staff member D told her that if the physician (staff member H) felt the patient was stable enough to be discharged and transported via private vehicle, it would be fine. Staff member E said she made a second phone call to staff member H and asked her to come in and evaluate patient #15 to determine if she was stable enough to go to [hospital B] via personal vehicle. Staff member E said she felt staff member H should have come to the ED and “lay hands” on patient #15. Staff member E stated staff member H told her that if all the information she was reporting was correct, patient #15 was not in active labor and was stable enough she could be discharged and go to [hospital B] via private vehicle. Staff member E said she discharged patient #15 via private vehicle to go directly to [hospital B]. During an interview on 6/18/25 at 9:05 a.m., staff member D said she told staff member E that the doctor should come in and evaluate the patient to determine if she is stable or unstable and able to go to another facility via private vehicle. During an interview on 6/25/25 at 11:24 a.m., staff member F, Director of the Birth Center, stated if a patient was to arrive with a rupture of membranes, earlier than 34 weeks and not in labor, the provider would come in to evaluate the patient’s stability and arrange for transport to another facility for a higher acuity of care. During an interview on 6/25/25 at 12:33 p.m., staff member I stated that any patient presenting to the ED in preterm labor requires a provider to come in and do an evaluation at the bedside and initiate the transfer to another facility through the call center. During an interview on 6/25/25 at 8:42 a.m., staff member H stated she was a provider at the facility. Staff member H said she received a call from staff member E informing her patient #15 had arrived at the ED and she was proven ruptured, was on the monitor and was not contracting. Staff member H said patient #15 was stable and could go via private vehicle to [hospital B], and there was no need for her to be transported by ambulance. Staff member H said she would have followed the facility protocol for transfer if she knew the facility protocol. During an interview on 6/18/25 at 9:38 a.m., NF1 said she was the provider on call for [hospital B] when patient #15 arrived. She stated she had not received a call or any contact from [hospital A] or staff member H prior to patient #15’s arrival. NF1 said she was contacted by the charge nurse on L&D (Labor & Delivery) around 2:00 a.m. informing her patient #15 had arrived at the facility. NF1 stated on arrival, patient #15’s examination showed she was dilated to 2.0 cm and 90% effaced, and this would be her first baby. NF1 said a preterm rupture of membranes was an emergency, as the patient could go into labor at any time. NF1 said if the transfer of patient #15 had been made through the correct process, she would not have accepted patient #15 because she knew the baby would require NICU services and the NICU was on diversion. NF1 stated they delivered the infant at [hospital B], then had to transfer the infant to the nearest hospital with a NICU bed available [hospital C]. Review of a facility policy, “Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed: “ ...2. A transfer will be an appropriate transfer if: ...B. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment; ... ...Additional Transfer-Related Situations ...4. Transfers for High Risk Deliveries. A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer even if a transfer agreement is in place. In addition, a provider certification that the benefits of transfer outweigh the risks of transfer is required for the transfer of a woman in labor. ...” Review of a facility policy, “Maternal Transport Policy,” with a revision date of 11/23, showed: “ ...1. Initial Screening ...b. Transport is indicated when, after assessment, it is determined that the patient requires advanced resources and skilled personnel at a higher level facility, or if it is expected that newborn will require higher level of neonatal care. ...Care prior to transport-stabilization of patient ...b. Prior to transport, consent is required from the mother regarding the transfer and documented on the transfer request form. ...3. Disposition of transfer a. All obstetrical transports are arranged following the Patient Transport Algorithm. ...” Review of a facility document, “Patient Transport Algorithm”, not dated, showed: -Physician or nurse calls [medical center name] Transfer Center to initiate transport of mother or infant ... -The Transfer Center will have a conference call with [Facility name] provider and [Medical Center Name] provider. -[Medical Center Name] provider accepts the patient transfer. The Transfer Center confirms bed availability for the patient. ...””

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code (LSC) recertification survey was performed on 3/11/24. Under this regulatory requirement, 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. The CAH building is associated with 2 other Business Occupancies, all in separate buildings. The building surveyed for this survey are as follows: N1- North Valley Hospital CAH 07- Behavioral Health 14- North Valley Physical Therapy (Surveyed under Chapter 38 New Business Occ.) The CAH was surveyed specifically using Chapter 19 Existing Health Care Occupancies. The building construction type was found to be Type II (111) for the main level and Type II (000) for the mechanical penthouses, and contains 7 smoke compartments. No new construction has occurred since the last survey of the facility on 8/17/16 to 8/19/16. The facility had 19 patients/residents at the time of 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 (LSC) recertification survey was performed on 3/11/24. Under this regulatory requirement, 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. The CAH building is associated with 2 other Business Occupancies, all in separate buildings. The building surveyed for this survey are as follows: N1- North Valley Hospital CAH 07- Behavioral Health 14- North Valley Physical Therapy (Surveyed under Chapter 38 New Business Occ.) The CAH was surveyed specifically using Chapter 19 Existing Health Care Occupancies. The building construction type was found to be Type II (111) for the main level and Type II (000) for the mechanical penthouses, and contains 7 smoke compartments. No new construction has occurred since the last survey of the facility on 8/17/16 to 8/19/16. The facility had 19 patients/residents at the time of survey. These requirements were not met as evidenced by the following deficiencies:”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to 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 3/11/24 at 11:20 a.m., the marked exit doors leaving the ER area, going to the materials hall 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. 2. During an observation on 3/11/24 at 11:22 a.m., the area in the materials corridor leading to imaging had marked exit signs leading to magnetically locked doors. This was set up as an “access-controlled” egress special locking arrangement. The motion detector was not a part of the system.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to maintain emergency lighting provided to occupants of the building in accordance with NFPA 101 Life Safety Code, 2012 Edition, Section 4.6.12.3. Findings include: 1. During an observation on 3/11/23 at 1:40 p.m., the “frog-eye” emergency lights in the occupancy were tested and failed to work. In this new business occupancy, emergency lighting is not required by the code due to none of the following three conditions existing: 1. The building is three or more stories in height. 2. The occupancy is subject to 50 or more occupants above or below the level of exit discharge. 3. The occupancy is subject to 300 or more total occupants. However, Section 4.6.12.3, states any life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 32381 Based on interview and observation, the facility failed to provide emergency lighting per NFPA 110 Standard for Emergency and Standby Power Systems 2010 Edition, Section 7.3.1. Findings include: 1. During an observation on 3/11/24 at 10:25, the generator was inspected. There was a “frog-eye” emergency light observed in the room housing the generator. It was not apparent if the light was backed by battery power as required. In an interview through email, staff member A stated, the electrician told them that the light was only hard wired to the generator, it was not a battery power backed light.”

“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 a photo-luminescent sign was installed in accordance with NFPA 101 2012 Edition, Section 7.10.7.2. Findings include: 1. During an observation on 3/11/24 at 11:35 a.m., there was a photo-luminescent exit sign at the imaging entrance. There was no continuous illumination near the face of the sign by a reliable light source to ensure “charging” of the sign in case of a power outage or an emergency.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 32381 Based on an observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7 Findings include: 1. During an observation on 3/11/24 at 11:12 a.m., the ambulance entrance was inspected. A fire alarm pull station near the exit door was blocked from instant access. 2. During an observation on 3/11/24 at 12:14 p.m., the pre-op exit door was inspected. There was a pull station near the door which was blocked from instance access.”

“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 an observation the facility: a) failed to ensure a sprinkler head was installed clear of a ceiling mounted fixture 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, b) failed to sprinkle the entire facility in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.1. Findings Include: 1. During an observation on 3/11/24 at 12:05 p.m., infusion bay 4 was inspected. A ceiling mounted rail system for privacy curtains was observed, obstructing a sprinkler head. The head was within 12 inches of the rail, and the rail was lower than the deflector on the sprinkler head. 2. During an observation on 3/11/24 at 12:07 p.m., the med records area was inspected. A new wall had been built recently which left an alcove without sprinkler coverage in the area.”

“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 maintain sprinkler heads free of foreign materials per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1. Findings include: 1. During an observation on 3/11/24 at 11:40 a.m., the soiled utility room by the OR was inspected. There was a large piece of material stuck to and hanging off the sprinkler head in the room.”

“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: 32381 Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1. Findings include: 1. During an observation on 3/11/24 at 1:31 p.m., the entry vestibule was inspected. The portable extinguisher in the room was found to be blocked from immediate access by items placed in the vestibule.”

“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 a corridor door resistant to the passage of smoke in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.2. Findings include: 1. During an observation on 3/11/24 at 11:55 a.m., Surgical supply room in the OR area was inspected. The corridor door was found to have four holes through the door where the door handle and latch were changed out at some point, leaving holes through the door.”

“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: 32381 Based on record review, the facility failed to ensure the fire safety plan and subsequent drills documented all requirements listed in the the code for responding to a fire drill per NFPA 101. 2012 Edition, section 19.7.1.2. Findings include: 1. Review of the facility fire drills going back a year reflected the facility lacked documentation in regards to all the elements required by code for the fire safety plan, specifically, the facility was not training staff to make a simulated emergency call to the fire department or 911. Even thouigh the system dialer will alert the monitoring agency, the code requires staff to still call 911 and report about the alarm.”

“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: 32381 Based on observation, 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. Findings include: 1. During an observation on 3/11/24 at 11:30 a.m., the materials hallway was inspected. There were two large rolling bins for linens left outside a protected room in the corridor. The largest size allowed to be unattended in the corridor is 32 gallons, one is allowed for garbage, and one is allowed for soiled laundry.”

“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: 32381 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). Findings include: 1. During an observation on 3/11/24 at 10:28 a.m., the area outside of receiving was inspected. There was an outlet cover missing on the red outlet near the door.”

“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 3/11/24 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.”

“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 Advanced Directives for 6 (#s 1, 2, 3, 4, 6, and 7) of 6 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 2/28/24, patients #1, 2, 3, 4, 6, and 7 medical records did not show an advanced directive was entered in the patients 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 2/28/24 at 11:00 a.m., two staff members, staff member B and staff member N, were asked to locate the Advance Directives in the medical records for patients 1, 2, 3, 4, 6, and 7. Staff member B and staff member N were unable to find the Advance Directives in the medical records, and they stated they were not sure where to find them. Staff member N stated the ER staff does not routinely ask patients about Advance Directives, and she stated she was sure she was not going to find them. During an interview and record review on 2/28/24 at 11:15 a.m., staff member N stated, “We do not routinely ask about code status or advanced directives. We would only have that discussion if someone was very critical. Typically, the nurses don’t do that anyway, it would be up to the doctor to ask.” Review of patient #3’s medical record showed the patient was a 94-year-old female who arrived in the ED via ambulance for a sudden onset of severe epigastric pain and nausea. When staff member N was asked if patient #3 would be the type of patient staff member N would consider “very critical,” she stated, “Yes, she would be someone that it would be important to know if she had advanced directives.” Staff member N stated it was not her expectation that her nursing staff would ask any patient about their advance directives or code status. She stated the doctor would do that, and the doctor would document that conversation in the medical record. Review of patient #3’s emergency physician documentation did not show the patient was asked about Advance Directives or her code status. During an interview on 2/28/24 at 2:40 p.m., staff member W stated the emergency department registration staff does not ask patients about Advance Directives. She stated registration staff only discussed Advance Directives if a patient asked about it, or brought their Advance Directives to the hospital to be scanned into their medical record. Staff member W stated registration staff does not keep any information concerning Advance Directives to give to patients to inform them of how they can obtain Advance Directives. Review of a facility policy titled, “Advance Directives,” dated 11/23, showed, “This facility endorses and respects each patient’s right to participate in decisions regarding their medical care. It is the intent of the facility to comply with the Patient Self Determination Act and carry out the wishes of patients in decision making.””