Bertrand Chaffee Hospital

“MEDICAL STAFF - APPOINTMENTS CFR(s): 482.12(a)(2) [The governing body must] appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This Standard is not met as evidenced by: 49203 Based on review of the hospital’s Medical Staff Bylaws, credential file, and interview, for one of one personnel file review, the facility failed to complete an appraisal and have a system established to examine credentials of individual prospective members (new appointments or reappointments) by the medical staff. The individual’s credentials to be examined must include a request for clinical privileges. Findings include: Review on 7/12/24 of the hospital’s Medical Bylaws, revised on 12/4/16, revealed “no practitioner shall be permitted to treat patients in the hospital until appropriate clinical privileges that define the scope of patient care services, they may provide independently in the hospital are delineated and approved in the manner set forth in these Medical Staff Bylaws and Rules and Regulations of the Hospital and the department thereof. Every physician, dentist, podiatrist, or allied health professional, practicing at this hospital by virtue of medical staff membership or otherwise shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to such medical staff member by the governing body.” Review of Medical Records on 7/12/2024 revealed Staff (WW), Nurse Practitioner performed cardioversions (procedure to restore regular heartbeat) on five of five patients, Patient #37 on 3/28/24, Patient #38 on 2/13/24, Patient #39 11/21/23, Patient #40 on 8/31/23, and Patient #41 on 8/24/23 without receiving approval to do so by the hospital’s department of medicine. Review of the credential file for Staff (WW), Nurse Practitioner on 7/11/2024, included the hospital document, “Department of Medicine: Delineation of Privileges for Allied Health Cardiology”, revealed Staff (WW) was granted medical privileges on 7/10/2024. The hospital’s governing board approved Staff (WW)’s request for reappointment to the allied health staff on 2/22/22. Between the dates of 2/22/2022 and 7/11/2024 there is no evidence of Staff (WW)’s delineation of privileges, specifically to perform cardioversions. The identified privileges granted were completing in-patient rounds, writing in progress notes and treatment orders which must be countersigned by an approved sponsoring medical doctor within 24 hours and to work in the Heart Center. Interview on 7/11/24 with Staff (A), Director of Patient Care Services verified these findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2) Training content. The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. This Standard is not met as evidenced by: 32261 Based on personnel file review, policy review, and staff interview, the facility does not ensure all staff with direct patient care responsibilities receive annual restraint education and have an annual restraint competency. Findings Include: Review on 07/11/24 of personnel and education files for Staff (H), Emergency Department Nurse Manager, Staff (O), Registered Nurse, Staff (X), Registered Nurse, Staff (Y), Licensed Practical Nurse, Staff (AA), Registered Nurse, Staff (BB), Registered Nurse, Staff (KK), Nursing Assistant, and Staff (LL), Nursing Assistant revealed no evidence of annual restraint training and annual restraint competency. Review on 07/12/24 of policy “Nursing Care Policy on Restraints and Seclusion”, last facility review on July 2022, revealed staff education includes all hospital staff with direct patient care responsibilities. Education occurs at orientation and yearly thereafter. Annual competency must be completed by all clinical staff. Interview on 07/12/24 at 10:00 AM and telephone interview on 07/16/24 at 12:05 PM with Staff (A), Director of Patient Care Services, confirmed these findings.”

“ELIGIBILITY & PROCESS FOR APPT TO MED STAFF CFR(s): 482.22(a) The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope of practice laws, the medical staff may also include other categories of physicians (as listed at §482.12(c)(1)) and non-physician practitioners who are determined to be eligible for appointment by the governing body. This Standard is not met as evidenced by: 32261 Based on record review, policy review, document review, and interview, for one of one Physician Assistants, the facility does not ensure there is Physician oversight of the care provided by Physician Assistants in the Emergency Department. Findings Include: Review on 07/12/24 of “Medical Staff By-Laws”, last facility review December 2016, revealed all Allied Health Professionals shall practice under a supervising physician or in collaboration with a physician who is a Medical Staff member, in that specific department, responsible for their supervision and direction as appropriate. The Allied Health Professional may, as appropriate, admit or discharge patients and may write or enter into the electronic medical record. The medical history and physical findings entered in the medical record by Allied Health Professionals must be countersigned by the Attending Physician. Review on 07/12/24 of policy “COBRA/EMTALA”, last facility revision July 2019, revealed a medical screening exam must be completed by a physician, nurse practitioner or physician assistant in addition to the triage assessment. Regulations require express written certification for transfer which must be signed by the medical doctor or the medical provider. Review on 07/12/24 of policy, “Transfer of Patient From Emergency Department to Another Facility”, last facility review October 2023, revealed the “Inter-Institutional Transfer From” is completed by the Physician for transfers. Interview on 07/09/24 at 02:45 PM with Staff (T), Physician, revealed there is only a Physician Assistant covering the Emergency Department from 07:00 PM to 07:00 AM. Staff (T) stated that they review all Emergency Department transfer every day for appropriateness. Staff (T) stated the transfer forms of patients transferred from the Emergency Department by a Physician Assistant are not signed off by an Attending. Review on 07/10/24 of Patient #4’s Emergency Department Record, dated 06/30/24, revealed on 06/30/24 at 02:37 PM, Patient #4 presented to the Emergency Department from home with complaints of abdominal pain and fever after eating a meal. Patient #4 had blood and urine taken for laboratory studies, received intravenous fluids and intravenous medications for nausea and pain, and had a Computerized Tomography (used to view internal structures) of the abdomen. At 04:46 PM, Staff (EEE), Physician, performed a medical screen exam. Laboratory results revealed high white blood cell count, elevated liver enzymes, and an elevated lactate. At 07:00 PM, Staff (CCC), Physician Assistant, assumed care of Patient #4. At 07:50 PM, Staff (CCC), Physician Assistant, ordered Patient #4 to be transferred to another facility for higher level of care. Staff (CCC), Physician Assistant, completed the “Inter-Institutional Transfer Form”, documenting cholecystitis (inflamed gallbladder) as the emergency medical condition, the accepting facility, and name of accepting of the accepting Attending. Staff (CCC), Physician Assistant, signed the transfer form. At 08:37PM, Patient #4 left the Emergency Department via ambulance. There is no documented evidence an Attending Physician reviewed the care provided to Patient #4 by Staff (CCC), Physician Assistant, was appropriate and there is no Attending co-signature on the transfer form. Review on 07/10/24 of Patient #5’s Emergency Department Record, dated 06/30/24 to 07/01/24, revealed on 06/30/24 at 10:00 PM, Patient #5 presented to the Emergency Department from home with complaints of abdominal pain and back pain at 24 weeks gestation (pregnant). At 10:37 PM, Staff (CCC), Physician Assistant, performed a medical screen exam. Patient #5 had blood taken for laboratory studies, received intravenous fluids, and oral medication. On 07/01/24 at 12:31 AM, Staff (CCC), Physician Assistant, documented care was complete and Patient #5’s case was discussed with an Attending Physician at another area hospital who accepted Patient #5 for transfer to their Emergency Department. Staff (CCC), Physician Assistant, completed the “Inter-Institutional Transfer Form”, documenting abdominal pain and pregnancy as the emergency medical condition, the accepting facility, and name of accepting Attending Physician. Staff (CCC), Physician Assistant, signed the transfer form. At 01:15 AM, Patient #5 left the Emergency Department via ambulance. There is no documented evidence an Attending Physician reviewed the care provided to Patient #5 by Staff (CCC), Physician Assistant, was appropriate and there is no Attending Physician co-signature on the transfer form. Review on 07/10/24 of Patient #7 Emergency Department Record, dated 07/02/24 to 07/03/24, revealed on 07/02/24 at 06:34 PM, Patient #7 arrived via ambulance with complaints of leg weakness and swelling. At 07:05 PM, Staff (T), Physician, performed a medical screen exam. Patient #7 had blood taken for laboratory studies, received intravenous fluids, and oral medication. At 08:29 PM, Patient #7 verbally expressed feelings of depression and suicidal ideations to staff and felt unsafe to be discharged. Staff (T), Physician, documented that Patient #7 was not psychiatrically stable for discharge. At 08:39 PM, Staff (BBB), Physician Assistant, assumed care of Patient #7. At 09:21 PM, Staff (BBB), Physician Assistant, documented that Patient #7’s case was discussed with an Attending Physician at another area hospital who accepted Patient #7 for transfer to their Emergency Department. Staff (BBB), Physician Assistant, completed the “Inter-Institutional Transfer Form”, documenting suicidal ideations as the emergency medical condition, the accepting facility, and name of accepting of the accepting Attending. Staff (BBB), Physician Assistant, signed the transfer form. On 07/03/24 at 01:05 AM, Patient #7 left the Emergency Department via ambulance. There is no documented evidence an Attending Physician reviewed the care provided to Patient #7 by Staff (BBB), Physician Assistant, was appropriate and there is no Attending Physician co-signature on the transfer form. Review on 07/10/24 of Patient #11 Emergency Department Record, dated 06/03/24, revealed on 06/03/24 at 12:47 AM, Patent #11 arrived at the emergency room from home with their parent with a chief complaint shortness of breath, fever, cough, runny nose and worsening symptoms of previously diagnosed bronchiolitis (lung infection common in young children and infants) and an ear infection. Patient #11 was nasally suctioned, given a medicated respiratory inhalation treatment and given acetaminophen (fever reducing medication) with positive effects. At 01:05 AM, Staff (BBB), Physician Assistant, performed a medical screen exam. At 01:18 Staff (BBB), Physician Assistant AM, documented that Patient #11’s case was discussed with an Attending Physician at another area hospital who accepted Patient #11 for transfer to their Emergency Department. Staff (BBB), Physician Assistant, completed the “Inter-Institutional Transfer Form”, documenting bronchitis and respiratory failure as the emergency medical condition, the accepting facility, and name of accepting of the accepting Attending. Staff (BBB), Physician Assistant, signed the transfer form. At 01:53 AM, Patient #11 left the Emergency Department via ambulance. There is no documented evidence an Attending Physician reviewed the care provided to Patient #11 by Staff (BBB), Physician Assistant, was appropriate and there is no Attending Physician co-signature on the transfer form. Interview on 07/12/24 at 10:00 AM and telephone interview on 07/16/24 at 12:05 PM with Staff (A), Director of Patient Care Services, verified these findings.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 42572 Based on observation and staff interview, the facility failed to ensure the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured. Findings Include: Observations on 07/10/24 at 1:10 PM on the first floor, in the corridor near shipping and receiving, revealed a wet ceiling tile. Water appeared to be leaking from a corroded hot water balancing valve located above the tile. Observations on 07/10/24 at 1:20 PM on the first floor, in the corridor adjacent to the x-ray restroom, revealed a wet ceiling tile with black and grey staining. Water appeared to be actively dripping from a heating, ventilation, and air conditioning plumbing line. Observations on 07/10/24 at 1:50 PM on the second floor, in the medical unit, revealed four ceiling tiles in the corridor by room #216 with stains and wet spots. Water was actively dripping from a copper pipe above the tiles. Observations on 07/10/24 at 2:20 PM on the second floor, in the medical unit, revealed two ceiling tiles between the nursing station and room 210 with stains and wet spots. Water was actively dripping from a heating, ventilation, and air conditioning duct above the tiles. Interview on 07/10/24 with Staff (E), Facility Manager, verified these findings while observed. Observations on 07/11/24 at 2:10 PM in the pharmacy, revealed an approximately two foot in diameter area of damaged plaster on the ceiling with an approximately one-inch hole in the center. Observations on 07/11/24 at 2:15 PM in the pharmacy, revealed a buildup of dust on and around three of three vents in the room. Interview on 07/11/24 at 2:15 PM with Staff (E), Facility Manager, verified these findings.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 32261 Based on observation, policy review, and interview staff do not ensure of the disposal of expired supplies preventing possible patient use. Findings Include: Review on 7/12/24 of policy “Emergency Department Crash Cart Checking”, last revised August 2023, revealed all supplies will be checked for expiration dates, any outdated supplies will be replaced. Observations on 07/09/24 in the Emergency Department revealed the following expired supplies: -At 10:30 AM in the pediatric code cart: one Cook airway exchange catheter expired on 04/07/24; two intravenous start kits expired on 03/03/24 and 03/30/24; one Nellacor pediatric color metric carbon dioxide detector expired 03/27/24; one Hudson high volume tapered cuffed tracheal tube expired on 05/20/24; three Broselow Hinkle pediatric emergency intubation system expired on 02/29/24; one Kendall suction catheter with compromised packaging; one 18 gauge autoguard intravenous catheter expired on 06/25/23; two provent arterial blood gas kits expired on 04/09/24; two Hudson high volume tapered cuffed tracheal tubes expired on 01/22/24. -At 10:40 AM in the medication room: five insulin syringes that expired on 04/30/24; 45 pediatric blood culture vials that expired on 02/21/24; 6 multi-test specimen swabs that expired on 02/29/24; 7 microorganism collection transportation system expired on 06/12/22; 21 microorganism collection transportation system expired on 06/03/23; and four microorganism collection transportation system expired on 04/02/23. -At 11:00 AM in the clean medical supply room: one 22 gauge intravenous catheter expired on 01/01/24; two pediatric emergency kits expired on 02/29/24; two sterile packaged metal vaginal speculums with compromised packaging; five fluid warming tubing kits expired on 08/19/23; one PICC line drape with sterile perforations kit expired on 09/08/23; four size 6 sterile gloves expired on 05/30/23; 10 size four sterile gloves expired on 03/01/24; and 8 Allevyn Sacrum dressings expired on 04/01/24. Interview on 07/09/24 at 11:15 AM with Staff (H), Emergency Department Manager, verified these findings. Interview on 07/12/24 at 10:00 AM and telephone interview on 07/16/24 at 12:05 PM with Staff (A), Director of Patient Care Services, verified these findings.”

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Health Care Facilities Sections of health care facilities classified as other occupancies meet all of the following: o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access. o They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. o The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served. 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623 This Standard is not met as evidenced by: 42572 Based on observation and staff interview, the facility does not ensure that the two-hour fire rated barrier separating the surgical suite from the medical unit is maintained. Findings Include: Observations on 07/10/24 at 1:40 PM on the second floor, above the drop ceiling over the 90-minute fire rated corridor doors to the surgery department, revealed an open space from the drop ceiling to the floor above spanning the width of the corridor without a two-hour fire rated barrier constructed. Interview on 07/10/24 at 1:40 PM with Staff (E), Facility Manager, verified this finding.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 42572 Based on observation and staff interview, the facility does not ensure that the openings in exit enclosures are limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure per The National Fire Protection Association (NFPA) 101, 7.1.3.2.1(9). Findings Include: Observations on 07/10/24 at 1:45 PM in the second-floor stairwell landing by room 216, revealed a 90-minute fire rated door to a heating, ventilation, and air conditioning (HVAC) mechanical closet. Interview on 07/10/24 at 1:45 PM with Staff (E), Facility Manager, verified that the 90-minute fire rated door to an HVAC closet in the stairwell did not meet the regulation.”

“Horizontal Exits CFR(s): NFPA 101 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 This Standard is not met as evidenced by: 42572 Based on observation and staff interview, the facility does not ensure that the horizontal exit is maintained with a minimum of a two-hour fire resistance-rated barrier. Findings Include: Observations on 07/10/24 at 1:00 PM on the first floor, above the drop ceiling over the 90-minute fire rated doors near the lobby, revealed information technology cables penetrating the two-hour fire barrier wall without a fire rated system in place. Interview on 07/10/24 at 1:00 PM with Staff (E), Facility Manager, verified this finding.”

“Suite Separation, Hazardous Content, and Subd CFR(s): NFPA 101 Suite Separation, Hazardous Content, and Subdivision All suites are separated from the remainder of the building (including from other suites) by construction meeting the separation provisions for corridor construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved barriers shall be allowed to continue to be used provided they limit the transfer of smoke. Intervening rooms have no hazardous areas and hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of suites shall be by noncombustible or limited-combustible construction. 18.2.5.7.1.2 through 18.2.5.7.1.4, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4 This Standard is not met as evidenced by: 42572 Based on observation and staff interview, the facility does not ensure that the suite separation barrier walls are maintained. Findings Include: Observations on 07/10/24 at 1:15 PM on the first floor, above the drop ceiling over the 45-minute fire rated doors to the 1988 addition, revealed a penetration along the top of the wall where the drywall meets the ceiling. The joint was not sealed leaving an approximately one-inch gap the width of the corridor without a one-hour fire rated system in place. Observations on 07/10/24 at 1:30 PM on the second floor, above the drop ceiling over the 45-minute fire rated doors to the critical care unit, revealed information technology cables penetrating the one-hour fire barrier wall without a fire rated system in place. Observations on 07/10/24 at 1:45 PM on the second floor, above the drop ceiling over the 45-minute fire rated corridor doors to respiratory care, revealed information technology cables penetrating the one-hour fire barrier wall without a fire rated system in place. Interview on 07/10/24 with Staff (E), Facility Manager, verified these findings as observed.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 42572 Based on observation and staff interview, the facility does not ensure that the Line Isolation Monitor (LIM), is tested at intervals of less than or equal to 1 month by actuating the LIM test switch. Findings include: Interview on 07/11/24 at 2:00 PM with Staff (E), Facility Manager, revealed that the Line Isolation Monitor identified during the facility tour in the emergency department was not being tested monthly and verified they were unaware of the testing requirement.”