Carrington Health Center

“PATIENT CARE SERVICES CFR(s): [The doctor of medicine or osteopathy-] (iv) Periodically reviews and signs the records of all inpatients cared for by nurse practitioners, clinical nurse specialists, or physician assistants. (v) Periodically reviews and signs a sample of outpatient records of patients cared for by nurse practitioners, clinical nurse specialists, certified nurse midwives, or physician assistants only to the extent required under State law where State law requires record reviews or co signatures, or both, by a collaborating physician. This Standard is not met as evidenced by: 27221 Based on record review, review of the facility’s “Medical Staff Rules & Regulations,” and staff interview, the Critical Access Hospital (CAH) failed to ensure a doctor of medicine or osteopathy periodically reviewed and signed the records of all inpatients cared for by a nurse practitioner (NP), physician’s assistant (PA), or clinical nurse specialist for 6 of 20 discharged patients (Patient #13, #14, #16, #17, #18, and #20) reviewed. Failure to periodically review and sign records of inpatients cared for by a NP, PA, or clinical nurse specialist limited the CAH’s ability to ensure the quality and appropriateness of the patient care provided. Findings include: Review of the CAH’s current “Medical Staff Rules & Regulations” occurred on 11/20/24. The rules and regulations stated, “. . . All entries by physician assistants and medical students shall be co-signed by a member of the active Medical Staff. . . .” On the afternoon of 11/18/24, the CAH provided a list of inpatient admissions from May 21-November 2, 2024. Review of the medical records occurred on all days of survey. The records identified a nurse practitioner or physician’s assistant admitted the following patients to the CAH, and failed to show a physician reviewed/signed the records: * Patient #13 admitted on 08/05/24. * Patient #14 admitted on 09/17/24. * Patient #16 admitted on 10/09/24. * Patient #17 admitted on 10/05/24. * Patient #18 admitted on 08/21/24. * Patient #20 admitted on 11/02/24. During an interview on 11/20/24 at 11:05 a.m., a managerial nurse (#1) confirmed she was unable to locate evidence a physician reviewed and signed Patient #13, #14, #16, #17, #18, and #20’s inpatient records.”

“PA, NP, & CLINICAL SPEC RESPONSIBILITIES CFR(s): Whenever a patient is admitted to the CAH by a nurse practitioner, physician assistant, or clinical nurse specialist, a doctor of medicine or osteopathy on the staff of the CAH is notified of the admission. This Standard is not met as evidenced by: 27221 Based on record review, review of the facility’s “Medical Staff Rules & Regulations,” and staff interview, the Critical Access Hospital (CAH) failed to ensure staff notified the medical doctor (MD) or doctor of osteopathy (DO) when a nurse practitioner (NP), physician’s assistant (PA), or clinical nurse specialist admitted a patient to the CAH for 5 of 20 discharged patients (Patient #7, #13, #17, #18, and #22). Failure of staff to notify the MD/DO of patients admitted by a NP, PA, or clinical nurse specialist limited the physician’s ability to ensure the appropriateness of the admission and to monitor the care provided to the patients. Findings include: Review of the CAH’s current “Medical Staff Rules & Regulations” occurred on 11/20/24. The rules and regulations stated, “. . . All entries by physician assistants . . . shall be co-signed by a member of the active Medical Staff. . . .” Review of patient medical records occurred on all days of survey. The records identified a NP or PA admitted the following patients to the CAH, and failed to show staff notified a physician of the admissions: * Patient #7 admitted on 07/20/24. * Patient #13 admitted on 08/05/24. * Patient #17 admitted on 10/05/24. * Patient #18 admitted on 08/21/24. * Patient #22 admitted on 07/30/24. During an interview on 11/20/24 at 11:05 a.m., a managerial nurse (#1) confirmed she was unable to locate evidence staff notified the physician when a NP or PA admitted Patient #7, #13, #17, #18, and #22.”

“This survey used the 2012 edition of NFPA 101, Life Safety Code, Chapter 19-Existing Health Care Occupancies and the 2012 edition of NFPA 99, Health Care Facilities Code in compliance with 42 CFR 482.41(b)(c). The findings that follow demonstrate noncompliance with these standards. Carrington Health Center was located in a one-story building of Type II (000) construction. The building had no basement. The facility was protected by a wet automatic sprinkler system designed to meet the requirements of the NFPA 13, Standard for the installation of Sprinkler Systems. Two-hour fire rated occupancy separation walls were constructed between the hospital and the attached clinic to the west.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 31888 Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1 A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3 System defects and malfunctions shall be corrected. NFPA 72 14.2.1.2.2 The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code. Review of fire alarm system test records indicated the pull station at the north entry by the Emergency Room had failed during the fire alarm system annual test conducted by an outside company on 10/15/2024 and had not been replaced at the time of the survey. Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire. The deficiency affected the complete fire alarm system, which serves the entire building.”

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 31888 Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years. 19.3.4.5, 9.6.2.10.1.1, NFPA 72 14.4.5.3 The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm and Signaling Code. Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72. Test records indicated the smoke detectors were last sensitivity tested on 09/09/2021 exceeding the required two-year test interval. The smoke detector sensitivity test results were not adequate to determine the use of the five-year interval. Failure to test the smoke detection system in accordance with NFPA 72 increases the risk of death or injury due to fire. This deficiency affected all smoke detectors in the facility.”