West River Regional Medical Center

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 19410 Based on bylaws review, record review, and staff interview, the Critical Access Hospital’s (CAH’s) governing body failed to ensure the appointment/reappointment for 2 of 8 provider (#1 and #2) credentialing files reviewed followed the medical staff bylaws. Failure to reappoint providers every two years and approve delineated privileges limited the governing body’s ability to ensure the CAH’s patients received treatment/services from qualified practitioners. Findings include: Review of the “West River Regional Medical Center Bylaws of the Medical Staff” occurred on 05/28/24 at 12:00 p.m. These bylaws, approved 12/18/19, stated, “. . . Article III: Medical Staff Membership 3.1 . . . Membership on the medical staff of the hospital is a privilege that shall be extended only to professionally competent physicians . . . who continuously meet the qualifications, standards and requirements set forth in these bylaws. . . . 3.3.2 . . . Reappointments shall be for a period of not more than two medical staff years. . . . 3.3.6 Appointment to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the governing body, in accordance with these bylaws. . . .” Review of the governing body’s bylaws, titled “Bylaws West River Health Services Hettinger, North Dakota,” occurred on 05/28/24 at 2:35 p.m. These bylaws, approved 10/23/20, stated, “ . . . Article V - Board of Directors . . . Section 6 Responsibilities. Responsibilities of the Board include: . . . maintain a qualified medical staff . . . Article XI - Medical Staff Section 1 . . . a. The Board of Directors shall organize the physicians and appropriate other persons granted practice privileges in the hospital into a medical staff under medical staff bylaws approved by the Chairman and the Board of Directors. The Board of Directors shall consider recommendations of the medical staff and appoint to the medical staff . . . physicians and others who meet the qualifications for membership as set forth in the bylaws of the medical staff. . . . c. . . . Re-appointments shall be for a period of not more than two medical staff years. . . . Section 2 . . . c. The medical staff shall make recommendations to the Chairman and the Board of Directors concerning: (1) appointments, re-appointments . . . (2) granting of clinical privileges . . .” Reviewed on 05/30/24, the CAH’s current credentialing records indicated the following: - Provider #1: the governing body last approved reappointment and privileges on 01/27/21, three years and four months ago. - Provider #2: the governing body approved the most current reappointment and privileges on 08/23/23, two years and three months after the previous appointment of 05/26/21. During an interview on the morning of 05/30/24, an administrative staff member (#2) confirmed the most current reappointments for Providers #1 and #2 exceeded two years from the past appointments; and Provider #1 provided cardiac consulting services and Provider #2 provided pathology consulting services during the periods listed above.”

“RESTRAINT AND SECLUSION CFR(s): The CAH must provide patient- centered, trauma informed competency- based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the use of restraint and seclusion. This Standard is not met as evidenced by: 27221 Based on review of personnel files, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, received patient-centered, trauma informed competency-based training and education regarding the use of restraints and seclusion in 2023 for 5 of 7 personnel files (Staff Member #3, #4, #6, #8, and #9) reviewed. Failure to ensure staff received the required annual education limited the CAH’s ability to ensure staff were knowledgeable regarding the use of restraints and seclusion. Findings include: Review of the facility policy titled “Use of Restraints” occurred on 05/30/24. This policy, dated 02/07/20, stated, “. . . Staff education/competency: All staff will have ongoing skills labs and training in the appropriate use of alternative strategies, identification of potential risk behaviors, correct application and removal of restraints . . . Use of Restraints: Strategies to meet emergent patient needs. Education begin at time of orientation. . . .” Review of seven randomly selected personnel files occurred on the afternoon of 05/30/24. Staff Member #3, #4, #6, #8, and #9’s files failed to include evidence of completed education regarding the use of restraints and seclusion in 2023. During an interview on 05/30/24 at 10:00 a.m., a human resources staff member (#10) confirmed Staff Members #3, #4, #6, #8, and #9 failed to complete the required annual education addressing the use of restraints and seclusion for 2023.”

“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 two-story building of Type II (000) construction that was protected throughout with an automatic sprinkler system designed to meet the requirements of NFPA 13, Standard for Installation of Sprinkler Systems. A two-hour fire rated occupancy separation wall was constructed between the hospital and the attached administration building to the east and an outpatient clinical building to the north. Note: West River Rehabilitation and Wellness Center and an attached clinic operated under the same provider number as West River Regional Medical Center and were also part of this survey.”

“Multiple Occupancies - Contiguous Non-Health CFR(s): NFPA 101 Multiple Occupancies - Contiguous Non-Health Care Occupancies Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served. 18.1.3.4.1, 19.1.3.4.1 This Standard is not met as evidenced by: 31889 The facility failed to ensure the fire resistance rating of occupancy separation walls. Fire doors shall latch upon closure. 19.1.3.4.1, 6.1.14.4.1, 8.3.3.1, NFPA 80 6.1.4.3.1 Observation determined the fire doors in the 2-hour barrier near the Lab Waiting Room failed to self-close and latch. Failure to ensure the fire resistance rating of occupancy separation walls as required increases the risk of death or injury due to fire. The deficiency affected one (1) of several doors located in 2-hour fire rated separation barriers in the facility.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 31889 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1 The facility failed to ensure exit access was readily available at all times. Observation determined the corridor door to the Janitor Closet near the Pharmacy opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened. Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire. The deficiency affected one (1) of numerous corridor doors in the means of egress throughout the facility.”

“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: 31889 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1 The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and latching doors. Observation determined the corridor door to the Laundry Room was equipped with a kick-down hold open device. The door was being held open at the time of this survey. Failure to ensure hazardous areas were separated from other spaces by smoke-resisting partitions increases the risk of death or injury due to fire. The deficiency affected one (1) of numerous hazardous areas in the facility.”

“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: 31889 The facility failed to install cooking equipment in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. 19.3.2.5.1, 9.2.3, NFPA 96 10.5.1. Observation determined the manual actuation device for the fire-extinguishing system serving the Kitchen exhaust hood was mounted at a height of more than forty-eight (48) inches above the floor. The manual pull was 60 inches above the floor. Failure to inspect, maintain, and install the wet chemical extinguishing system in accordance with NFPA 96 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.”

“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: 31889 Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system. Sprinklers in high-temperature zones shall be of the high-temperature classification. 19.3.5.1, 9.7.1.1(1), NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2). 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. Observation determined one (1) sprinkler in the walk-in freezer lacked fluid in the sprinkler glass bulb. Failure to install and maintain the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire. The deficiency affected one (1) of numerous sprinklers in the facility. The automatic sprinkler system serves the entire facility.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 31889 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, they shall have a fire resistance rating of not less than ½ hour and they shall resist the transfer of smoke. 19.3.6.2.1, 19.3.6.2.2, 19.3.6.2.3 The facility failed to ensure corridors were separated from use areas by walls with at least ½-hour fire resistance rating and constructed to resist the transfer of smoke. Observation determined the corridor wall near the Pharmacy Janitor Closet had 5 holes through the wall, preventing the resistance of smoke. Failure to separate corridors from other areas increases the risk of death or injury due to fire. The deficiency affected one (1) of numerous corridor walls in the facility.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 31889 Fire dampers shall be tested and inspected in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. All tests shall be completed in a safe manner by personnel wearing personal protective equipment. Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 19.5, NFPA 80, 19.4 The facility failed to test and inspect fire dampers as required by NFPA 80. Documentation was not available to determine testing of fire dampers throughout the facility. Failure to maintain fire dampers in accordance with NFPA 80 increases the risk of death or injury due to fire. This deficiency affected all fire dampers in the facility.”

“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: 31889 The facility failed to conduct fire drills as required. Fire drill records review determined: 1) No fire drills were conducted on the third Shift during the second quarter in the past year. 2) No fire drills were conducted on the second Shift during the third quarter of 2023. 3) No drills were conducted on the first, second, and third shifts during the fourth quarter of 2023. Failure to conduct fire drills as required increases the risk of death or injury due to fire. The deficiency affected five (5) of twelve (12) drills in the past year.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 31889 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this code. 8.3.3.1. Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2 The facility failed to inspect and test fire rated door assemblies throughout the facility. Review of documentation and interview with staff determined fire rated doors throughout the facility have not been inspected and tested in the past year. Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire. The deficiency affected all fire rated door assemblies throughout the facility.”

“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: 31889 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 areas other than kitchens where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. NFPA 70, 210.8, 210.8(A)(7) The facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. Observation determined an electrical receptacle in the Dirty Utility Room near the O.B. was installed within 6 ft. of a sink and was 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 one of numerous 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: 31889 The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems. Documentation was not available indicating the emergency generator was exercised for 4 continuous hours in the past 36 months. 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.”