Huggins Hospital

“RADIOLOGY SERVICES CFR(s): §485.635(b)(3) Radiology services. Radiology services furnished by the CAH are provided by personnel qualified under State law, and do not expose CAH patients or personnel to radiation hazards. This Standard is not met as evidenced by: 40522 Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to periodically check all personnel who are regularly exposed to radiation for the level of radiation exposure. Findings include: Review on 7/10/24 of the Dosimetry Badge reports for 2024 revealed that the report did not have Dosimetry Badge results for the orthopedic surgeons that worked in the operating room. Interview on 7/10/24 at approximately 10:30 a.m. with Staff A (Director of Medical Imaging) confirmed the above findings. Further interview with Staff A revealed that the orthopedic surgeons that worked in the operating room did not have Dosimetry Badges. Interview on 7/11/24 at approximately 1:30 p.m. with Staff B (Director of Surgical Services) revealed that the orthopedic surgeons utilize the C-arm when they perform surgeries on patient’s with fractures, total hip replacements, and pain procedures performed in the operating room. Staff B confirmed that the orthopedic surgeons did not have Dosimetry Badges.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 43002 Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to have accurate records for 1 of 20 patients reviewed for inpatient records (Patient Identifier #6). Findings include: Review on 7/11/24 of Patient #6’s physician’s orders revealed an order for Full Code dated 7/3/24. Further review of Patient #6’s physician’s orders revealed an order for Do Not Resuscitate (DNR) signed by Staff D (Medical Doctor) on 7/6/24. Review on 7/11/24 of Patient #6’s physician’s progress notes completed by Staff D revealed under Assessment/Plan that “Full Code” was documented on 7/6/24, 7/7/24, 7/8/24, 7/9/24, 7/10/24. Further review of the progress notes revealed no additional documentation regarding Resident #6’s code status. Review on 7/11/24 of Patient #6’s medical record, including advanced directives, case manager notes, and nursing notes revealed no documentation regarding Resident #6’s change in code status. Interview on 7/11/24 at 11:45 a.m. with Staff E (Director of Acute Care) confirmed that there was no additional documentation for Patient #6’s DNR status. Interview on 7/11/23 at 2:45 p.m. with Staff F (Chief Medical Officer) revealed that Patient #6’s above progress notes should have reflected the updated DNR status. Review on 7/11/24 of the facility’s 5/18/07 policy titled “Advanced Directives” revealed: “... 6. If a patient is capable of making decisions, then the patient’s expressed preferences and decisions...should direct the patient’s care plan. The patient has the right to clarify, modify, or revoke an Advance Directive at any time. If this occurs, changes need to be documented in the medical record...””

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 33306 NFPA 80 Standard for Fire Doors and Other Opening Protectives 4.2.1 Listed items shall be identified by a label. 4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ after installation of the assembly. 4.2.3 The label or listing shall be considered evidence that sampling of such devices or materials have been evaluated by tests and that such devices or materials are produced under an in-plant, follow-up inspection programs. 5.2 Inspections 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.4 Swinging Doors with Builders Hardware of Fire Door Hardware. 5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of the door assembly. 5.2.4.2 As a minimum, the following items shall be verified. (1) No open holes or breaks exist in the surface of the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self closing device is operational: that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. Based on observations and interview, it was determined the facility failed to ensure three fire-rated door assemblies could automatically close to a full latched position when released from the magnetic hold-open devices. Findings include: Observations during tour on 7/10/24 between 12:00 p.m. and 3:30 p.m. with Staff A (Chief Information Officer) and Staff B (Manager of Plant Operations) revealed three fire rated door assemblies that failed to close to a full latched position when released from the magnetic hold-open devices. The three fire door locations and existing conditions are as follows: 1. The 45-minute fire rated cross corridor door assembly, located on the basement level outside room A-000 (Training Room), failed to automatically close to a latched position. The rated door sweep on the right hand door panel was slightly dragging on the floor, preventing the door from closing. 2. The 90-minute fire rated cross corridor door assembly, located between the main lobby and the Emergency Department corridor, failed to automatically close to a latched position when released from the magnetic hold-open device. The closing force of the door assembly was slightly less than needed. 3. The 90-minute fire rated cross corridor door assembly, located on the second floor elevator lobby, failed to automatically close to a latched position when released from the magnetic hold-open device. The rated door sweep on the right hand door panel was slightly dragging on the floor, preventing the door from closing. Interview on 7/10/24 with Staff A and Staff B confirmed the above findings, locations, and existing conditions.”

“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: 33306 NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (2011 edition) 6.3.2 Hydrostatic Tests. 6.3.2.1 Hydrostatic tests of not less than 200 psi pressure for 2 hours, or at 50 psi in excess of the maximum pressure, where maximum pressure is in excess of 150 psi, shall be conducted every 5 years on manual standpipe systems and semi-automatic dry standpipe systems, including piping in the fire department connection. 6.3.3.2 Hydrostatic tests shall be conducted in accordance with 6.3.2.1 on any system that has been modified or repaired. 6.3.2.3.1 The inside standpipe piping shall show no leakage. 13.4.4.2 Testing 13.4.4.2.1 The priming water level shall be tested quarterly. 13.4.4.2.2 Each dry pipe valve shall be trip tested annually during warm weather. 13.4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. 13.4.4.2.2.3 During those years when full flow testing in accordance with 13.4.4.2.2.2 is not required, each dry pipe valve shall be trip tested with the control valve partially open. 13.4.4.2.5 A tag or card that shows the date on which the dry pipe valve was last tripped, and the name of the person and organization conducting the test, shall be attached to the valve. Based on record review and interview, it was determined the facility failed to ensure vendor identified sprinkler system deficiencies (Fire Department Connection (FDC)) were corrected in a timely manner, and two dry-type sprinkler systems failed to receive the required three year full trip test. Findings include: Record review during tour on 7/10/24 between 7:30 a.m. and 10:30 a.m. with Staff A (Chief Information Officer) and Staff B (Manager of Plant Operations) revealed the professional sprinkler vendor service reports, dated 9/23/21 and 3/02/22, stated the FDC failed the inspection and required the 5-year Hydrostatic testing. The repairs and FDC Hydrostatic testing was conducted and completed on 6/21/24. Additionally, the two dry-type sprinkler systems received a full trip test on 6/24/19 and were due for continued maintenance on or before 6/24/22 (every three years). Documents and inspection cards affixed to the sprinkler system risers still list the last full trip test as being completed on 6/24/19. Interview on 7/10/24 with Staff A and Staff B confirmed the above findings, conditions, and available documentation. Contact with the sprinkler system vendor confirmed the full trip testing had not been completed as of this survey date.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 33306 NFPA 101 Life Safety Code (2012 edition) 8.5 Smoke Barriers 8.5.2.1 Smoke barriers required by this code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. 8.5.6.2 Penetrations for Cables. Cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall floor, or floor/ceiling assembly constructed as a smoke barrier, or a through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. Based on observations and interview, it was determined the facility failed to ensure smoke barrier penetrations were maintained (sealed) to resist the passage of smoke or the effects from fire. Findings include: Observations during tour on 7/11/24 between 12:00 p.m. and 2:00 p.m. with Staff A (Chief Information Officer) and Staff B (Manager of Plant Operations) revealed the following two locations with unprotected penetrations through the smoke barrier wall: 1. Above the suspended ceiling in the Emergency Department entrance foyer, had a 1 1/2 inch unprotected penetration from a Flexible Metal Conduit (FMC) passing through the smoke barrier wall. 2. Above the suspended ceiling between the main lobby and the Medical Arts building entrance, had an area of fire stopping that had at least two different fire stopping products mixed together in the same penetration. Interview on 7/11/24 with Staff A and Staff B confirmed the above findings, locations, and existing conditions.”