Kearney County Health Services Hospital

“ANESTHETIC RISK AND EVALUATION CFR(s): (1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed. (2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia. (3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in paragraph (c) of this section. This Standard is not met as evidenced by: 46123 Based on record review, review of facility policy and staff interviews, the Critical Access Hospital (CAH) failed to ensure a physican examined 4 (patient 26, 28, 29, 30) of 6 surgical patients immediately before surgery to evaluate the risk of the procedure to be performed. The CAH also failed to ensure an anesthesia provider examined 4 (patient 26, 28, 29, 30) of 4 before surgery to evaluate the risk of anesthesia. This failed practice has potential to effect all surgical patients treated at the CAH. The facility had 347 surgical patients for fiscal year 24. Findings are: A. Review of Patient 26’s medical record (6/24/25 at 11:15 AM) revealed patient 26 was admitted 1/23/25 at 5:46 AM for a left total knee replacement (artificial parts are used to replace damaged ends of bones). The physician evaluation for risk of procedure was signed by the physician on 1/23/25 at 9:01 AM The anesthesia provider examination lacked a time when the note was completed. Review of surgery intraoperative note revealed surgery started at 7:45 AM. - Review of Patient 28’s medical record (6/25/25 at 9:00AM) revealed patient 28 was admitted 3/20/25 at 7:34 AM for bilateral myringotomy with tube placement (tubes inserted behind the ear drum to help drain fluid backup in the middle ear) and bilateral adenoidectomy (removal of adenoid glands located behind the nose above the roof of the mouth). The physician evaluation for risk of procedure lacked a signature at time of the record review. The anesthesia provider examination lacked a time when the note was completed. Review of surgery intraoperative note revealed surgery started at 8:21 AM. - Review of Patient 29’s medical record (6/26/25 at 8:00AM) revealed patient 29 was admitted 3/21/25 at 11:15 AM for esophagogastroduodenoscopy (EGD, procedure using a small flexible tube with camera to look inside the mouth down to the stomach and start of small intestine) and colonoscopy (procedure using a long flexible tube with a camera to look inside the colon or large intestine).The physician evaluation for risk of procedure was signed by the physician 3/21/25 at 11:18 PM. The anesthesia provider examination lacked a time when the note was completed. Review of surgery intraoperative note revealed surgery started at 12:26 PM. - Review of Patient 30’s medical record (6/25/25 at 1:20 PM) revealed patient 30 was admitted 4/4/25 at 7:30 AM for Minimally Invasive Surgery right foot; derotational osteotomies of toes 2,3,4 (procedure to straighten the toes). Hemiphalangectomy right 2nd toe distal interphalangeal joint (removal of part of bone at the joint closest to the tip of the toe. The physician evaluation for risk of procedure was signed by the physician 4/21/25 at 11:26 AM. The anesthesia provider examination lacked a time when the note was completed. Review of surgery intraoperative note revealed surgery started at 8:57 AM. B. Review of policy Evaluation of Surgical Patients by Anesthesia (Last date reviewed 7/1/2024) revealed, qualified practitioners who perform surgery at CAH will examine the patient immediately before surgery to evaluate the patient’s risk for surgery. - Qualified anesthesia providers shall examine each patient before surgery to evaluate the risk of anesthesia. This will be documented on the anesthesia record. C. Interview (6/26/25 at 12:45 PM) with the Chief Nursing Officer (CNO) revealed her agreement of confirmation of missing documentation for each patient identified (patient 26, 28, 29 and 30).”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 27395 Based on record review and staff interview, the facility failed to test the battery system of the emergency generator. This condition increased the likelihood of the generator failing to start during loss of power. Findings are: Record review of monthly generator load test reports on 6/25/25 at 12:51 pm revealed there was no documentation of monthly specific gravity testing or conductance testing for the lead-acid batteries. In an interview on 6/25/25 at 12:51 pm, Maintenance A confirmed the generator battery was not tested, but only the voltage readings were taken from the generator panel. NFPA 110, 2010, 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.”

“42 CFR 483.90(a)(b) 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 18, New Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Kearney County Health Services is a one story building of Type II (000) construction that was remodeled in 2018 - Lab, and is fully fire sprinkler protected. There is supervised smoke detection located in the corridors. The facility has a capacity of 10 beds. Kearney County Health Services was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a)(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“42 CFR 483.90(a)(b) 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. Kearney County Health Services is a one story building of Type II (000) construction that was built between 1969 - 2015, and is fully fire sprinkler protected. There is supervised smoke detection located in the corridors. The facility has a capacity of 10 beds. Kearney County Health Services was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a)(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“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: 27395 Based on observation and staff interview, the facility failed to provide a means to ensure the range was correctly positioned under the suppression system nozzles, and that the appliance was anchored to protect the natural gas connection. This condition would increase the probability of a gas leak or failure to suppress a cooking fire. Finding are: Observation on 6/25/25, at 12:00 pm revealed: 1. The range was not provided with floor markings or wheel chocks to ensure the range was returned to an aligned position with the range hood suppression system nozzles when the appliance is moved. 2. The range was not anchored to prevent the natural gas hose from disconnecting when the appliance is moved. In an interview on 6/25/25, at 12:00 pm, Maintenance A confirmed the findings. NFPA 17A, 2009, 5.6.4 Movable cooking equipment shall be provided with a means to ensure that it is correctly positioned in relation to the appliance discharge nozzle during cooking operations. NFPA 54, 2012, 9.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer’s installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connector installation shall be configured in accordance with the manufacturer’s installation instructions. 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer’s installation instructions.”

“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: 27395 Based on observation and staff interview, the facility failed to ensure the fire alarm circuit was properly identified and secured. This condition increased the potential that power to the fire alarm would be shut off when not intended. Findings are: Observation on 6/25/25 at 11:35 am revealed circuit breakers that fed fire alarm panels were not marked in red or locked in life safety panel XLS1. In an interview on 6/25/25 at 11:35 am, Maintenance A confirmed the findings. NFPA 72, 2010, 10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking. 10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.”

“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: 27395 Based on observation and staff interview, the facility failed to ensure the fire alarm circuit was properly identified and secured. This condition increased the potential that power to the fire alarm would be shut off when not intended. Findings are: Observation on 6/25/25 at 11:35 am revealed circuit breakers that fed fire alarm panels were not marked in red or locked in life safety panel XLS1. In an interview on 6/25/25 at 11:35 am, Maintenance A confirmed the findings. NFPA 72, 2010, 10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking. 10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.”

“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: 27395 Based on observation, record review and staff interview, the facility failed to have fire sprinkler gauges replaced or tested at the required 5-year interval. This condition increased the potential for false pressure readings. Findings are: Observation on 6/25/25 at 11:44 am revealed gauges on the main fire sprinkler riser were dated 2019. Record review on 6/25/25, at 11:44 am of the 1/9/25 fire sprinkler inspection report did not indicate testing of the gauges. In an interview on 6/25/25 at 11:44 am, Maintenance A confirmed the gauges were dated 2019, and that no other documentation was available. NFPA 25, 2011, 5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.”

“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: 27395 Based on observation, record review and staff interview, the facility failed to have fire sprinkler gauges replaced or tested at the required 5-year interval. This condition increased the potential for false pressure readings. Findings are: Observation on 6/25/25 at 11:44 am revealed gauges on the main fire sprinkler riser were dated 2019. Record review on 6/25/25, at 11:44 am of the 1/9/25 fire sprinkler inspection report did not indicate testing of the gauges. In an interview on 6/25/25 at 11:44 am, Maintenance A confirmed the gauges were dated 2019, and that no other documentation was available. NFPA 25, 2011, 5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3 This Standard is not met as evidenced by: 27395 Based on record review and staff interview, the facility failed to limit circuits essential to life safety on a life safety branch of the essential electrical system (EES). This condition increased the potential of EES failure. Findings are: Record review on 6/25/25 at 11:36 am of the life safety panel XLS1 panel schedule revealed the following circuits were not life safety items or could not be adequately identified: 7: main server, 13: illegible, 23/25: illegible, 27: office/illegible, 29: mechanical room, 31/33 basement, 4: telephone board recepts, 6: telephone board recepts, 8: telephone board recepts, 20: UPS-COS-CLOS, 30: UPS Business Office. In an interview on 6/25/25 at 11:36 am, Maintenance A acknowledged not all items in the panel were life safety, or was unsure of the descriptions. NFPA 99, 2012, 6.4.2.2.3 Life Safety Branch. 6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety. 6.4.2.2.3.2 The life safety branch shall supply power for lighting, receptacles, and equipment as follows: (1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code (2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code (3)*Hospital communications systems, where used for issuing instruction during emergency conditions (4) Generator set location as follows: (a) Task illumination (b) Battery charger for emergency battery-powered lighting unit(s) (c) Select receptacles at the generator set location and essential electrical system transfer switch locations (5) Elevator cab lighting, control, communications, and signal systems (6) Electrically powered doors used for building egress (7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code 6.4.2.2.3.3 Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch. 6.4.2.2.3.4 Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices. 6.4.2.2.3.5 No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3.”

“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: 27395 Based on record review and staff interview, the facility failed to test the battery system of the emergency generator. This condition increased the likelihood of the generator failing to start during loss of power. Findings are: Record review of monthly generator load test reports on 6/25/25 at 12:51 pm revealed there was no documentation of monthly specific gravity testing or conductance testing for the lead-acid batteries. In an interview on 6/25/25 at 12:51 pm, Maintenance A confirmed the generator battery was not tested, but only the voltage readings were taken from the generator panel. NFPA 110, 2010, 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.”