Daniels Memorial 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 6/12/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies of NFPA 101. The building construction type was found to be Type V (111); it contains 4 main floor and 2 basement smoke compartments. There has been no new construction since the last survey on 07/16/19. Both the Nursing Home and the Critical Access Hospital were surveyed. The physical separation of the two for reporting purposes was considered to be the smoke barrier wall from the elevator shaft to the conference room on the main level and the set of fire doors by the elevator shaft in the lower level. The Rural Health Care occupancy was not surveyed due to a two-hour barrior present. These requirements were not met as evidenced by the following deficiencies:”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 40068 Based on an observation the the facility failed to assure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1, 19.3.2.1.3 and 19.3.2.1.5 (7). This deficiency affects 1 of 6 smoke compartments. Findings include: During an observation on 6/12/24 at 12:10 p.m., the PT storage room was inspected. The room was being used as storage, was 81 square feet, and the door leading to the room lacked a self-closure.”

“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 interview and record review the facility failed to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2. This deficiency affected all smoke compartments in the facility. Findings include: Review of sprinkler inspection records on 6/12/24 showed there was not a sprinkler inspection completed for the first quarter of 2024 (January - March). During an interview on 6/12/24 at 11:20 a.m., staff member B stated there was not a sprinkler inspection completed for the first quarter of 2024. Staff member B stated the inspector was sick and pushed back the inspection into the second quarter of 2024.”

“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 an 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. This deficiency affected 1 of 6 smoke compartments in the facility. Findings include: During an observation at 6/12/24 at 12:16 p.m., the boiler room was inspected. A portable fire extinguisher was observed, blocked by storage of various items.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 47752 Based on observation, interview, and record review, the facility failed to ensure expired supplies in the pediatric crash cart, expired medications in the crash cart, and expired supplies in the emergency department were replaced prior to their expiration date. This deficient practice had the potential to affect any patient requiring the need for these supplies or medications. Findings include: During an observation on 6/4/24 at 11:05 a.m., the pediatric crash cart was observed to have the following items: -1 pink pediatric Broselow/Hinkle airways oxygen delivery module with an expiration date of 3/31/24, -1 pink pediatric Broselow/Hinkle airways oxygen delivery module with an expiration date of 4/30/24, -1 pink I-gel pediatric airway (2-5 kg) with an expiration date of 11/2023, -1 blue I-gel pediatric airway (5-12 kg) with an expiration date of 11/2023, -1 Miller S-1 glidescope with an expiration date of 9/24/23, -1 LoPro S2 glidescope airway (1.8-10 kg) with an expiration date of 9/20/22, -1LoPeo S2 glidescope airway (10-18 kg) with an expiration date of 5/31/22, -1 purple Broselow/Hinkle pediatric airway system with an expiration date of 2/29/24, -1 purple Broselow/Hinkle pediatric airway system with an expiration date of 5/31/24, -1 yellow Broselow/Hinkle pediatric airway system with an expiration date of 2/28/24, -1 white Broselow/Hinkle pediatric airway system with an expiration date of 2/28/24, -1 white Broselow/Hinkle pediatric airway system with an expiration date of 2/29/24, -1 blue Broselow/Hinkle pediatric airway system with an expiration date of 2/28/24, -1 blue Broselow/Hinkle pediatric airway system with an expiration date of 2/28/24, -1 orange Broselow/Hinkle pediatric airway system with an expiration date of 2/28/24, -1 orange Broselow/Hinkle pediatric airway system with an expiration date of 2/29/24, -1 orange Broselow/Hinkle pediatric airway system with an expiration date of 5/31/2, -1 green Broselow/Hinkle pediatric airway system with an expiration date of 2/28/24, -1 green Broselow/Hinkle pediatric airway system with an expiration date of 2/29/24, -1 green Broselow/Hinkle pediatric airway system with an expiration date of 5/31/24, and -1 white I-gel pediatric airway (25-35 kg) with an expiration date of 11/2023. During an observation at 11:25 a.m., the crash cart was observed to have the following expired medications: -2 multidose vials of Nitroglycerin 50mg/10ml with an expiration date of 4/24, -2 multidose vials of Potassium Chloride 40mEq/20ml with an expiration date of 2/1/24, and -4 1000ml IV bags of 5% dextrose and 0.45% sodium chloride with an expiration date of 3/24. During an interview on 6/4/24 at 11:30 a.m., staff member I stated it was her responsibility to look for outdated items in the emergency room. Staff member I stated she had just got done going through the emergency room looking for outdated items. Staff member I stated she checked the emergency room weekly at a minimum, but she usually did so three to five times a week. During an observation on 6/4/24 at 11:40 a.m., the following ED supplies were observed to be expired: -4 gastroccult test cards with an expiration date of 10/23, -78 FUL-GLO fluorescein sodium sterile ophthalmic strips 1.0 mg with an expiration date of 3/31/24, and -1 tube of 100 silver nitrate applicators with an expiration date of 3/24. During an interview on 6/4/24 at 12:45 p.m., staff member B stated, “[staff member I] goes though the crash carts and looks for expired items in the locked areas and CS does all the other supplies. I am not sure why those items were missed. I know [staff member I] just went through the ER looking for expired medications.” During an interview on 6/5/24 at 9:00 a.m., staff member AA stated, “I do not check the crash carts, they are to be locked. It is my understanding that if it is locked, I do not touch it. That is nursing’s responsibility. I do check IV fluids and was surprised that expired IV bags were found. I’m not sure where those came from.” A review of a facility policy titled, “Emergency Drugs and Biologicals,” undated, showed the policy lacked information regarding expired supplies in the Emergency Room.”

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to inform patients and/or their representatives of their rights prior to providing or discontinuing care for 2 (#s 22 and 23 ) of 23 sampled patients. This deficient practice had the potential to affect the exercise of rights for all patients receiving care in the facility. Findings include: A review of patient #22’s medical record showed the patient had come to the emergency department on 5/6/24 and was transferred to another facility on 5/6/24. There was no signed acknowledgement of patient rights in the medical record. A review of patient #23’s medical record showed the patient had come to the emergency department on 5/29/24 and was discharged home on 5/29/24. There was no signed acknowledgement of patient rights in the medical record. During an interview on 6/5/24 at 1:16 p.m., staff member B stated the facility did not have a signed acknowledgement of patient rights in the emergency department. Staff member B stated, “We really should have the patient sign them (patient rights acknowledgement).” Review of a facility policy titled, “Social Services Resident Rights,” with an effective date of 3/2018, showed: “Facility (Scope): Nursing Home, Critical Access Hospital, and Intermediate Swing Beds.” The policy did not include or address patient rights for the Critical Access Hospital, only the swing bed intermediate patients.”