Ira Davenport Memorial Hospital

“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: 42572 Based on observation and interview, the hospital did not maintain all corridor walls with a minimum ½-hour fire resistance rating. Findings include: Observation on 12/03/25 at 11:25 AM, on the ground floor, above the drop ceiling over the doors to the radiology suite, revealed a 2- inch round hole penetrating the 1-hour rated corridor wall without a fire rated system in place. Observation on 12/03/25 at 11:57 AM, on the basement floor outside the laboratory, above the drop ceiling over electrical panel number 52, revealed a flexible metal electrical conduit penetrating the 1-hour rated corridor wall without a fire rated system in place to seal around the conduit. Interview on 12/03/25 at 12:00 PM with Staff (V), Hospital Administration and Staff (W), Facilities, verified this finding.”

“Delivery of services. CFR(s): (b)(3) Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use. This Standard is not met as evidenced by: 48608 Based on policy review, observation, and interview, the hospital failed to ensure expired medications are removed and unavailable for patient use. Findings include: Review of the policy “Pharmacy Purchasing and Shelf Stocking,” revised October 2023, revealed expired drugs should be segregated from routine stock until they can be sent to a reverse distributer, if appropriate. Observation on 12/02/25 at 12:05 PM in the surgical services area medication room refrigerator revealed one vial of Humalog Insulin (hormone to prevent sugar build-up in blood) that expired on 10/06/25, two vials of Succinylcholine (paralytic drug) that expired in September 2025, and one vial of Anectine (paralytic drug) that expired in October 2025. Interview 12/02/25 at 12:05 PM with Staff (N), Registered Nurse, verified this finding.”

“Notice of rights. CFR(s): (a) (1) An REH must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48506 Based on policy review, document review, medical record review, and interview, for 28 of 29 medical records reviewed, the hospital failed to ensure patients are provided a copy of the Patient’s Bill of Rights (Patients #1 to Patient #14 and Patient #16 to Patient #29). Findings include: Review of the policy “Patient Rights,” dated October 2024, revealed the emergency department personnel will give a copy of the Patient’s Bill of Rights to the patient or their representative at the time of registration. A copy of the Medicare Patient’s Rights will be distributed to each Medicare patient or their representative. Review of the document “General Consent,” no date, revealed a general consent for treatment form that did not include a sign off that patients were provided a copy of the Patient’s Bill of Rights. Review of medical records for Patients #1 to Patient #14, and Patients #16 to Patient #29, revealed no evidence the patients received a copy of the Patient’s Bill of Rights. Interview on 12/04/25 at 09:20 AM with Staff (A), Hospital Administration, verified these findings.”

“Privacy and safety. CFR(s): (c)(2) Receive care in a safe setting. This Standard is not met as evidenced by: 48506 Based on policy review, medical record review, review, and interview, for one of five records reviewed, staff failed to conduct 15-minute safety checks (Patient #1). Findings include: Review of the policy “Management of Suicidal Patient and Environment,” dated June 2025, revealed the patient’s suicide risk severity classification determines the level of observation required. High and moderate risk patients with suicidal ideation associated with planning, intent and/or suicidal action or attempt will require in-person (1:1 monitoring). Suicide precaution patients must be a 1:1 observation and always be in “line of sight,” where the sitter has an unobstructed vision of the patient at all times. The nurse has primary documentation responsibility. The 1:1 sitter will document on the sitter observation record at least every 15 minutes throughout the duration of sitting with the patient. The patient must remain on 1:1 observation until the physician has discontinued the patient from needing a 1:1 sitter. Review of the medical record for Patient #1, dated 10/15/25, revealed the following: -At 01:39 PM, Patient #1 presented ambulatory to the emergency department for an insulin (medication to lower blood sugar) overdose. -At 01:46 PM, Staff (R), Physician, documented a medical screening exam that indicated Patient #1 had a history of multiple suicide attempts. Patient #1 injected themselves with five Novolog (insulin - medication to lower blood sugar) pens. Patient #1 was positive for suicidal ideas with a plan. Patient #1 confirmed the suicide attempt and will require a mental health evaluation after medical clearance. Patient #1 required transfer to a higher level of care for continued hourly monitoring of their blood glucose levels. -At 01:59 PM, Patient #1 was assessed as high risk for suicide on the Columbia Suicide Screening Rating Scale (suicide risk level screening exam). -At 02:01 PM, Staff (R), Physician, placed an order for every 15-minute safety checks and Staff (Z), Registered Nurse (RN), placed an order for suicide precautions. -From 02:01 PM until 03:29 PM, no 15-minute safety checks were documented. -From 04:00 PM until 07:15 PM, there was documentation Patient #1 was on 1:1 observation. -At 07:16 PM, Patient #1 was transferred to another hospital for a higher level of care. Interview on 10/03/25 at 12:00 PM with Staff (P), Registered Nurse, verified this finding.”

“Facilties. CFR(s): (b)(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: 42572 Based on policy review, observations, and interview, the hospital failed to ensure expired supplies are removed and not available for use and does not test the emergency eyewash station weekly as required by the American National Standard Institute Z358.1 2014: Emergency Eyewash & Shower Standard. Findings include: Review of the policy “Cleaning, Equipment and Supplies,” revised December 2025 revealed the medical/surgical, emergency department, and surgical services staff are responsible for checking for outdated items and rotation of supplies. Observation on 12/02/25 at 12:10 PM in Room #206 revealed a cabinet with seven swab & oral cleansing kits that expired 11/30/25. Interview on 12/02/25 at 12:10 PM with Staff (N), Registered Nurse, verified this finding. Observation on 12/03/25 at 10:50 AM in the second floor solied utility room revealed an eyewash station with a weekly inspection log. Review of the log indicated the last testing of the eye wash station was completed on 08/13/25. Interview on 12/03/25 at 11:00 AM with Staff (V), Hospital Administration and Staff (W), Facilities, verified this finding.”