Lincoln Surgical Hospital

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 44712 Based on review of Medical Staff Rules and Regulations, medical record review and staff interview, the facility failed to ensure documentation of physician orders for discharge in accordance with facility’s Medical Staff Rules and Regulations for 3 of 30 medical records(Patients 8, 13, 19) reviewed. This failed practice had the potential to affect all patients of the hospital. The hospital had 13,052 surgical cases for fiscal year 2022. Findings include: A. Review of facility’s Medical Staff Rules and Regulations (approved January 2019) revealed that a patient may be discharged only on the order of the admitting physician or designee practitioner. B. Review of Patient 8’s medical record (12/5/23 at 1:43 PM) revealed the patient was admitted on 8/7/23for a Robotic Assisted Sleeve Gastrectomy (surgical removal of a part or whole of the stomach) and lacked documentation of a physician order for discharge. -Review of Patient 13’s medical record (12/6/23 at 12:32 PM) revealed the patient was admitted on 10/20/23for a Robotic Right Colectomy (surgical removal of all or part of the colon) and lacked documentation of a physician order for discharge. -Review of Patient 19’s medical record (12/6/23 at 3:51 PM) revealed the patient was admitted on 6/22/23 for a Laparascopic Sleeve Gastrectomy (surgical removal of a part or whole of the stomach) and lacked documentation of a physician order for discharge. C. Interview with Nursing Service Leader (12/7/23 at 10:56 AM) confirmed the above medical records lacked evidence of a documented physician order for discharge.”

“42 CFR 483.70(a) The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Lincoln Surgical Hospital is a three story building of Type II (III) construction that was built in 1994 (with remodeled areas separated by 2-hour construction in 1999,2005,2010 and 2011) and is fully sprinklered. There is supervised smoke detection located in the corridors and all open areas to the corridor. The facility has 20 certified beds. At the time of the survey the census was 20.”

“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: 13879 Based on observation and interview, the facility failed to maintain multiple means of egress free of obstructions. This deficient practice would delay egress and not impede it to full instant use in the case of fire or other emergencies. The facility has the capacity for 20 beds with a census of 20 on the day of survey. Findings are: Observations on 12-6-23 at 10:42 am revealed: 1. Storage of towels in the corridor outside room 318. 2. Patient recyclable equipment stored in the corridors. During interview on 12-6-23 at 10:42 am, Staff A confirmed the items in the corridor. Nurse Staff A stated those items remain there all the time or until company replaces the bag.”

“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: 13879 Based on observation and staff interview, the facility failed to provide smoke resistant enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke and gases to migrate into the exit corridors. The facility has the capacity for 20 beds with a census of 20 on the day of survey. Finding are: Observation on 12-6-23 between 10:23 and 11:20 am, revealed the following: 1. A room within Patient Room 301 was used for storage and no door was provided, only a curtain. 2. Second floor Preop storage room measured over 50 square feet; the door failed to provide a self-closing device. 3. Second floor Preop storage room door was obstructed with medical equipment. 4. Patient room 101 was used as a storage room, no self-closing device was provided. 5. Patient room 102 was used as a storage room, no self-closing device was provided. 6. Patient room 103 was used as a storage room, no self-closing device was provided. 7. Patient room 104 was used as a storage room, no self-closing device was provided. During interview on 12-6-23 between 10:40 am and 11:20 am, Staff A confirmed the findings.”

“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: 13879 Based on observation and interview, the facility failed to assure that patient doors would latch within the doorframe. This deficient practice would allow fire, smoke and gases to enter the exit corridor or into the room and would delay egress. The facility has the capacity for 20 beds with a census of 20 on the day of survey. Findings are: Observations on 12-6-23 at 10:07 am and 11:18 am revealed: 1. Patient Room 306 failed to latch within the doorframe. 2. Pantry doors in the Dining room were held open with wooden chocks. During an interview on 12-6-23 at 10:07 am and 11:18 am, Staff A confirmed the findings.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 13879 Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and increase the potential for a larger fire which affected all smoke compartments and all occupants. The facility has the capacity for 20 beds with a census of 20 on the day of survey. Findings are: Record review on 12-6-23, at 11:55 am revealed the plan failed to include removal of items in the corridors. During an interview on 12-6-23, at 11:55 pm, Staff A confirmed the information was not present in the fire procedure.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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. Chapter 10 (NFPA 99) This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility failed to prohibit the use of electrical adaptors. This deficient practice would create electrical injury and increase a fire hazard. The facility has the capacity for 20 beds with a census of 20 on the day of survey. Findings are: Observation on 12-6-23 at 11:36 am revealed, a six-plex electrical adaptor at the ESA supply inventory manager’s desk. During an interview on 12-6-23 at 11:36 am, Staff A confirmed the use of electrical adaptor.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 13879 Based on observation and interview, the facility allowed the use of extension cords for permanent wiring. This deficient practice could increase the potential for an electrical fire. The facility has the capacity for 20 beds with a census of 20 on the day of survey. Finding are: Observations on 12-6-23 at 10:14 am and 11:15 am revealed: 1. A power-strip used for permanent wiring in the 3rd floor ice room. 2. An extension cord plugged into another extension cord under the food serving tables in the dining room. During interview on 12-6-23 at 11:04 am and 11:15 am, Staff A confirmed the use of the power strip and the extension cord.”