Cavalier County Memorial Hospital Association

“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: 20497 Based on complaint information, policy review, emergency department (ED) central log review, record review, and patient/staff interview, the Critical Access Hospital (CAH) failed to enforce policies to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 for 1 of 1 sampled patient (Patient #1) who presented to the CAH for a blood pressure check. Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements at §489.24. Failure of the CAH to enforce their Emergency Medical Treatment and Labor Act policy limited the CAH’s ability to determine if the patient had an emergency medical condition. Findings include: The CAH failed to ensure an ED provider conducted an appropriate medical screening examination within the capability of the CAH’s ED (Refer to C2406).”

“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: 20497 Based on complaint information, policy review, emergency department (ED) central log review, record review, and patient/staff interview, the Critical Access Hospital (CAH) failed to ensure a qualified medical person provided a medical screening examination for 1 of 1 sampled patient (Patient #1) who presented to the CAH for a blood pressure check. Failure to provide a medical screening examination limited the CAH’s ability to determine if the patient had an emergency medical condition. Findings include: Review of complaint information occurred on 10/22/24. The complaint information indicated the patient presented to the hospital in February or March 2023 and was not seen by a medical provider. Review of the policy “EMTALA Guidelines for Emergency Department Services” occurred on 10/23/24. This policy, revised 09/30/20, stated, “Definitions: . . . Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not. North Dakota has interpreted this statement to mean a MD [medical doctor], DO [doctor of osteopathy], NP [nurse practitioner], or PA [physician assistant]. . . . Policy: . . . All patients presenting to Cavalier County Memorial Hospital’s Emergency Department seeking care, or presenting elsewhere on the hospital’s main campus and requesting emergency care, must be accepted and evaluated regardless of the patient’s ability to pay. In the absence of an actual request for services, if a ‘prudent layperson’ observer would believe, based on the individual’s appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment. . . . All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capacity of the hospital to reach a diagnosis. . . .” Review of the 2023-2024 ED central log occurred the afternoon of 10/22/24. The log failed to include an entry for Patient #1 in February-March 2023. Review of Patient #1’s medical record occurred the morning of 10/23/24. The record included the following: - An ambulance patient care record, dated 03/24/23, stated, “. . . Vitals were taken and the . . . blood pressure remained high during the duration of being in the rig. . . . was continued to be monitored due to blood pressure. . . . refused to be transported by ambulance to the hospital. Due to continued high blood pressure . . . was advised to be seen at the hospital for a follow up. . . . agreed and once he left the rig he drove himself to the hospital for a follow up. . . .” - A progress note by a nursing staff member (#1), dated 03/31/23 at 21:43, stated, “. . . presents ambulatory stating, ‘the ambulance staff said I should come in and get my blood pressure checked because it was really high when they checked it.’ . . . house fire . . . was exposed to the smoke. . . . denies shortness of breath and chest pain. . . . was asked to sit for 15 minutes to relax then writer would check it. . . . was in agreement. . . . states he has a ‘little headache’ and that it’s ‘probably from the smoke’. . . . denies wanting to be seen in the ED. Blood pressure was 128/98 and pulse was 80. . . . is encouraged to get plenty of fresh air and come back if headache worsens or any other symptoms develop. . . . .” An addendum to the note by an administrative nursing staff member (#2), dated 05/03/23 at 5:16 p.m., stated, “. . . The date of service on the above was 03/24/23. Patient is stating he did not say he refused emergency room. . . .” - The record failed to include evidence of a medical screening examination by a qualified medical person. During interview on 10/22/24 at 3:05 p.m., an administrative nursing staff member (#3) stated she has told staff not to do routine blood pressure checks on patients that present for a blood pressure check. If staff does provide just a blood pressure check, they are to chart in [name of electronic record]. If staff had concerns, they would refer the patient to the ED. During interview on 10/22/24 at 4:12 p.m., Patient #1 stated there was a house fire on 03/24/23. He was seen by ambulance staff on-site and they recommended to have his blood pressure rechecked at the hospital. He said he asked the ambulance staff to call the hospital to let them know he would be coming. He entered the hospital around 8:40 p.m. via the main entrance. An aid called him by name and took him to an observation room by the nurses’ station. The nurse checked his blood pressure. The nurse made a comment about his lower number being on the higher side but that it could be because he just came from the incident site and his adrenaline was still high. The nurse told him if he was feeling any problems later to return to the ED. Patient #1 stated he did not remember stating to hospital staff why he presented to the ED as he was recommended to do so by the paramedics at the incident site and they were going to call the hospital. He stated the nurse did not recommend he be seen by a provider. During interview on 10/23/24 at 8:05 a.m., an administrative ambulance staff member (#4) stated he remembered treatment of Patient #1 in March 2023 after a fire incident. He said ambulance staff did an initial evaluation of Patient #1 in the ambulance, and Patient #1 declined an ambulance transfer to the hospital. He said ambulance staff called the hospital to inform them Patient #1 was on his way to the hospital. During interview on 10/23/24 at 10:55 a.m., a nursing staff member (#1) stated she recalled the incident with Patient #1 on 03/24/23. She said when Patient #1 came to the hospital he stated his blood pressure was high and was told to get it rechecked. She checked his blood pressure which was a little high. She also checked his oxygen saturation level which was within normal limits. She said she told Patient #1 that if he needed to be seen in the ED for any shortness of breath or anything else that may be related to the fire, the ED was available 24/7. Nursing Staff Member #1 stated she asked Patient #1 multiple times if he wanted to be seen in the ED, but he refused. She stated the ED provider also laid eyes on the patient and offered ED services, but the patient declined. Upon request on 10/22/24 and 10/23/24, the CAH failed to provide a policy regarding blood pressure checks at the hospital and failed to provide a listing of patients who received blood pressure checks at the hospital.”

“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 485.623(d)(e). The findings that follow demonstrate noncompliance with these standards. The facility was located in a one-story building of Type II (000) construction with a full basement and an automatic sprinkler system designed to meet the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. A two-hour fire resistive rated barrier separates a clinic attached to the south side of the hospital. Note: A Fire Safety Evaluation System (FSES) was conducted as a result of the 04/16/2024 Life Safety Code survey. The FSES was specifically used as an alternative safety method for Tag K271 (Discharge from Exits). The facility passes the FSES when all other deficiencies have been corrected.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 31888 The facility failed to ensure exit access was readily accessible at all times. Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1 To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways. Observation determined the northeast and east exterior exits traversed the lawn to get to a public way. Failure to ensure exit access was readily available at all times increases the risk of death or injury due to fire. The deficiency affected two (2) of eight (8) exits from the facility.”

“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: 31888 Testing of required emergency lighting systems shall be permitted to be conducted as follows: 1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds. 2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. 3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered. 4) The emergency lighting equipment shall be fully operational for the duration of the tests. 5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 7.9.3.1.1 The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting. Record review determined: 1) The facility failed to conduct a 30-second monthly test of the emergency battery back-up lights during all months in the past year. 2) The facility failed to conduct a 90-minute annual test of the emergency battery back-up lights in the past year. Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire. The deficiency affected all emergency battery back-up lights throughout the building.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 31888 The facility failed to test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems. On a monthly basis, inspection shall be conducted in accordance with the manufacturer’s listed installation and maintenance manual or the owner’s manual. At a minimum, this quick check or inspection shall include verification of the following: 1) The extinguishing system is in its proper location. 2) The manual actuators are unobstructed. 3) The tamper indicators and seals are intact. 4) The maintenance tag or certificate is in place. 5) No obvious physical damage or condition exists that might prevent operation. 6) The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range. 7) The nozzle blowoff caps, where provided, are intact and undamaged. 8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated. If any deficiencies are found, appropriate corrective action shall be taken immediately. Where the corrective action involves maintenance, it shall be conducted by a trained service technician. Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions. At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections. 7.2.1 through 7.2.6 Review of documentation and interview with staff determined the monthly inspection of the wet chemical extinguishing system in the Kitchen had not been completed during February, and March 2024. Failure to conduct monthly inspections of the wet chemical extinguishing system increases the risk of injury or death due to fire. This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.”

“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. 2010 NFPA 72, 14.1.1 The facility failed to test the fire alarm system as required. Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e). Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 12/21/2023. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year. 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. This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.”

“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: 31888 Health care facilities shall be protected throughout by an approved, supervised automatic fire sprinkler system. 19.3.5.3, 19.3.5.4, 9.7.1.1(1) The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide adequate coverage for all portions of the building. Sprinklers in high-temperature zones shall be high-temperature classification, and sprinklers in intermediate-temperature zones shall be intermediate-temperature classification. NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2) NFPA 13 requires high-temperature-rated sprinklers within a 7 ft. radius cylinder extending 7 ft. above and 2 ft. below horizontal discharge unit heaters. Observation determined one (1) sprinkler in the Loading Dock installed within 7 ft. of a horizontal discharge unit heater was not high-temperature-rated. Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire. This deficiency affected one (1) of numerous areas in the facility. The automatic sprinkler system serves the entire facility.”

“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: 31888 Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 4.1.4.1 The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25. 1) Record review and interview with staff determined the control valves and gauges of the automatic sprinkler system had not been inspected during all months in the past year. 2) Record review and interview with staff determined quarterly flow tests of the automatic sprinkler system were not completed as required. Records did not indicate a flow test was conducted during the second quarter in the past year. Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire. The deficiency affected the complete automatic sprinkler system, which serves the entire facility.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 31888 The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code. Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens, rooftops, outdoors, indoor wet locations, locker rooms with associated showering facilities, garages and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(B) Observation determined: 1) Two (2) electrical receptacles in the Kitchen were not ground-fault circuit-interrupter protected. 2) Two (2) electrical receptacles in PT Room 1 within 6 ft. of a sink were not ground-fault circuit-interrupter protected. 3) Two (2) electrical receptacles in Sleeping Room 1 within 6 ft. of a sink were not ground-fault circuit-interrupter protected. Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire. The deficiency affected six (6) of numerous electrical receptacles in the facility.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 31888 The facility failed to ensure the emergency generator was in compliance with NFPA 99 and NFPA 110. Record review and interview with staff determined: 1) The weekly inspection of the emergency generator was not conducted for all weeks during the past year. 2) The monthly load tests of the emergency generator during the past year exercised the emergency generator under load for 15 minutes not the required 30 minutes. Failure to inspect, test and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire. The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.”