Ashtabula County Medical Center

“SYSTEM MEDICAL STAFF COMPOSITION CFR(s): 482.22(b)(4)(iii) [§482.22(b)(4) - If a hospital is part of a hospital system consisting of multiple separately certified hospitals and the system elects to have a unified and integrated medical staff for its member hospitals, after determining that such a decision is in accordance with all applicable State and local laws, each separately certified hospital must demonstrate that:] (iii) - The unified and integrated medical staff is established in a manner that takes into account each member hospital’s unique circumstances and any significant differences in patient populations and services offered in each hospital; and This Standard is not met as evidenced by: 44810 Based on record review and staff interview, the facility failed to provide timely nephrology consultation for a resident, who was dependent on hemodialysis, admitted to the facility in heart failure and fluid overload and required emergency hemodialysis. This affected one (#1) of ten patients reviewed for hemodialysis. The facility census was 215. Findings include: Review of the medical record for Patient #1 revealed he arrived at the emergency department (ED) via ambulance on 08/20/25 at 12:28 A.M. Patient #1 had complaints of shortness of breath. His triage started at 12:29 A.M. and he was assigned an acuity level of two, which indicated he required an extensive amount of care. Patient #1 was administered intravenous (IV) Solu-Medrol (potent anti-inflammatory medication), insulin, and Lokelma (hyperkalemia [high potassium] treatment) due to his potassium level being 6.3 millimoles per liter (mmol/L) (normal range is 3.6 to 5.2 mmol/L with a level of 6.0 being potentially dangerous). Patient #1 was also found to have a pro-brain naturetic peptide (proBNP - hormone released by the heart in response to increased stress/measures the amount of fluid in the body and helps regulate blood pressure [BP]) of 201,000 pictograms per milliliter (pg/mL), strongly indicative of heart failure. A chest X-ray revealed Patient #1 had pulmonary edema. Patient #1 was diagnosed with heart failure and fluid overload. Patient #1 had an episode of low BP while in the emergency room, which was treated with midodrine (treats low BP) 10 milligrams (mg) and provided good results. Patient #1 was a hemodialysis patient who went to outpatient dialysis every Monday, Wednesday, and Friday. Patient #1 reported he had dialysis on Monday, but he only received half of the treatment due to cramping. Further review of the ED notes revealed Patient #1 was to be admitted to the hospital to receive dialysis treatment. Patient #1 was discharged from the ED on 08/20/25 at 4:53 A.M. and was admitted to a medical-surgical (med-surg) floor. Additional review of a rapid response team note dated 08/20/25 at 7:04 A.M. revealed Patient #1 was experiencing worsening shortness of breath. He was administered IV Solu-Medrol, given a nebulizer treatment, placed on a non-rebreather high flow oxygen mask, and ordered emergency dialysis due to fluid overload. Review of the physician orders revealed a nephrology consult was not ordered until 08/20/25 at 8:09 A.M. Review of the nephrology consult note dated 08/20/25 revealed the nephrologist was notified about Patient #1 being admitted to the hospital as the patient was known to him in the community. The nephrologist was not notified by the hospital, but he received consultation from the dialysis nurse looking for orders to start emergency dialysis at 8:05 A.M. The nephrologist reported that he was eventually notified of a routine consultation from the floor at 8:09 A.M. The note also revealed that Patient #1 was seen around two hours into dialysis, he was confused and his BP was low, but that was not uncommon as Patient #1 was dependent on midodrine. Patient #1 denied chest pain. Review of the rapid response note dated 08/20/25 at 12:15 P.M. revealed that Patient #1 became unresponsive two hours and 10 minutes into his dialysis treatment. Patient #1’s code status was Do Not Resuscitate-Comfort Care (DNR-CC), so physicians administered fluids to increase his heart rate and BP, with no success. Patient #1 was pronounced dead at 11:35 A.M. Interview on 10/07/25 at 10:31 A.M. with the ED Director, Staff I, revealed the ED had 24 beds. Staff I reported dialysis treatments were not completed in the ED but if a patient presented to the ED and required dialysis, they would be admitted and treated or transferred for care. Telephone interview on 10/08/25 at 8:40 A.M. with Registered Nurse (RN) Staff J revealed she responded to the rapid response team call on 08/20/25 at 6:50 A.M. for Patient #1. She reported that Patient #1 became extremely short of breath. He was treated with DuoNeb nebulizer and Solu-Medrol. An electrocardiogram (ECG) and troponin (measures for heart damage) levels were tested. Staff J reported that it was decided Patient #1 required emergency dialysis, and she returned to the intensive care unit (ICU) where she was working. Telephone interview on 10/08/25 at 8:45 A.M. with Senior Director of Inpatient Dialysis Staff K and Dialysis RN Staff L confirmed that the inpatient dialysis team was notified of the need for emergent dialysis for Patient #1 on 08/20/25 at 6:55 A.M. Staff L reported that she was already on her way to the facility because she had other patients that required treatment for the day and she arrived at the facility at 7:35 A.M. Staff K reported that they had two hours to get to the facility for emergency cases and reported that only the nephrologist could write orders for dialysis treatment. Staff L reported the nephrologist typically notified them of the need for emergency dialysis, but the call she received that morning was from the charge nurse on the med-surg floor. Staff K reported she called the nephrologist at 8:05 A.M. that morning to get orders to administer a dialysis treatment to Patient #1 and he informed her he did not even know Patient #1 was in the hospital. He gave her orders, and she started Patient #1’s dialysis treatment around 9:10 A.M. Staff K reported Patient #1 was alert and oriented during the treatment. He was short of breath but able to have conversation with her and his vital signs were stable. Staff K reported that around 11:00 A.M., during his treatment, the nephrologist came in to check on Patient #1 with no concerns. Around 11:30 A.M., Patient #1 began losing his pulse and his BP dropped. Staff L immediately called a rapid response. Due to Patient #1 being identified with a DNR-CC code status, the physician ordered a bolus of fluid and Patient #1 still decompensated and was pronounced dead at 11:35 A.M. Telephone interview on 10/08/25 at 9:07 A.M. with RN Staff M confirmed she cared Patient #1 while he was in the ED. She reported Patient #1 arrived short of breath. It was a Tuesday night when he arrived and reported he only had partial dialysis treatment the day prior due to cramping and he had been short of breath since the night prior. Patient #1 attended outpatient dialysis treatment every Monday, Wednesday, and Friday. Staff M reported Patient #1 was scheduled for outpatient dialysis treatment that morning (Wednesday) at 5:00 A.M. That was reported to the physician while they were deciding whether to admit or discharge Patient #1. Staff M reported that Patient #1 was admitted to the fourth floor (med-surg) and left the ED in stable condition around 4:30 A.M. Staff M confirmed Patient #1 was alert and oriented, his vital signs were stable, and his wife was with him as she did not leave the bedside during his stay. Telephone interview on 10/08/25 at 9:24 A.M. with ED Physician Staff N confirmed he cared for Patient #1 in the ED on 08/20/25. He reported Patient #1 presented as a dialysis patient with shortness of breath. Patient #1 was found to have a high potassium level, a high proBNP test, and pulmonary edema. He reported that Patient #1 required dialysis so when he spoke with the admitting physician, he informed him to notify the nephrologist of the need. He did not follow up with Patient #1 after he was admitted to the medical floor. Interview on 10/08/25 at 9:29 A.M. with Staff A and D revealed the admitting physician (a contracted Hospitalist) for Patient #1 was no longer employed by the Hospitalist group and was not working at the facility. Telephone interview on 10/08/25 at 9:30 A.M. with House Supervisor Staff Q revealed she was the house supervisor the night Patient #1 was admitted to the hospital. She reported she was informed Patient #1 was going to need dialysis during his stay but not that it was an emergency case. Staff Q reported that normally she reached out to the dialysis team after hours when emergency dialysis was ordered but since it was not ordered, she verified she did not notify them of Patient #1’s urgent need for dialysis. Telephone interview on 10/08/25 with Nephrologist Staff O revealed he was not notified of the fact Patient #1 was in the hospital or needed emergency dialysis until 08/20/25 at 8:05 A.M., when he was notified by his dialysis nurse. Staff O reported that was unusual since the hospital normally notified him and then he would give the dialysis order and notified the dialysis team. Staff O reported that the admitting physician never reached out to him regarding Patient #1’s need for emergency dialysis. Staff O confirmed that Patient #1 expired during his dialysis treatment, and he felt that Patient #1 could have had a different outcome if he had received dialysis sooner. Telephone interview on 10/08/25 at 10:52 A.M. with Physician Staff P revealed that he was called to the rapid response for Patient #1 on 08/20/25 at 11:20 A.M. and the patient was receiving dialysis. Staff P reported Patient #1 was absent of a pulse when he arrived and had extremely low BP. Staff P reported he ordered a fluid bolus for Patient #1, which he did not respond to. Due to Patient #1’s code status of DNR-CC, no other life saving measures were administered and Patient #1 expired. Interview on 10/08/25 at 4:15 P.M. with Chief Medical Officer Staff R confirmed that all emergency or urgent consults should have a doctor to doctor conversation within one hour of the patient arriving at the facility (Patient #1 arrived at 12:29 A.M. and the nephrologist was not contacted until 8:05 A.M.). Review of the facility root cause analysis related to Patient #1’s care at the facility, dated 08/22/25, revealed the nephrologist was not made aware of the patient’s need for dialysis until approximately eight hours after arrival, hemodialysis should have been ordered sooner, the house supervisor was not made aware of the urgent hemodialysis need timely, RNs did not escalate the urgent need for hemodialysis, the Hospitalist did not enter the hemodialysis order after discussion with the ED physician, the dialysis order was entered as routine and not STAT (immediate) once it was finally placed, and Patient #1 was admitted to a med-surg unit instead of ICU. Further review revealed a need to develop and implement a standardized process for consults from the ED physicians to the Hospitalists, a need to establish an escalation process for increased laboratory (lab) values, a need for a direct system to close communication based on patient results, and utilize house supervisor as a resource for admissions were identified action step. New processes were implemented and staff education on the new processes was completed on 08/25/25. Review of the Medical Staff Rules and Regulations/Policies and Procedures, updated March 2024, revealed admitting procedures included to ensure that patients had appropriate orders at the time of admission to the floor to ensure quality care. All orders for treatment shall be documented by the staff member responsible for the patient who shall receive such treatment. Review of the facility policy for inpatient services general and administrative guidelines, published 02/03/25, revealed emergency treatments must be ordered by a treating physician.”

“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: 42375 Based on observation and staff interview the facility failed to maintain fire rated construction of separated occupancies in accordance with NFPA 101 2012 Edition Sections 19.1.3 through 19.1.3.3, and 8.2.1 through 8.2.1.3. This deficient practice had the potential to affect all patients who reside within the hospital. Findings include: Observations during the tour of the facility with the Director of Maintenance (DM) on 01/08/24 between 8:30 A.M. and 3:00 P.M. identified fire separations not maintained. The second floor was currently under active construction, however, pipe chases and areas around electrical conduits discovered in vertical and horizontal fire barriers were not sealed. Further observation identified no active construction was not being performed at the time survey. Interview with the DM verified the finding at the time of observation. 19.1.3 Multiple Occupancies. 19.1.3.1 Multiple occupancies shall be in accordance with 6.1.14. 19.1.3.2 Sections of health care facilities shall be permitted to be classified as other occupancies in accordance with the separated occupancies provisions of 6.1.14.4 and either 19.1.3.3 or 19.1.3.4. 19.1.3.3* Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: (1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation. (2) They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. (3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 8.2 Construction and Compartmentation. 8.2.1 Construction. 8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters. 8.2.1.2* NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. 8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following: (1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge FireWalls, FireWalls, and Fire BarrierWalls, exists between the portions of the building (2) Separate buildings, if provided with previously approved separations (3) Least fire-resistive construction type of the connected portions, if separation as specified in 8.2.1.3(1) or (2) is not provided”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 42375 Based on observation, record review, and staff interview, the facility failed to ensure Fire Watch Policy was developed and being conducted accordance with NFPA 101 - 2012 Edition 19.3.5.1; 9.7.5, and NFPA 25 - 2010 Edition 15.5. This deficient practice had the potential to affect all patients who reside within the hospital. Findings include: Record review on 01/08/25 in the facility between 8:20 A.M. and 11:50 A.M. it was noted that the Fire Watch Policy did not address the proper procedure for assigning individuals to conduct a fire watch. The Fire Watch is to be a continuous surveillance of the area/s of the facility in which the sprinkler system is out of service. The second-floor sprinkler system was not intact and under renovation. No fire watch was being conducted throughout the affected area of the facility. Record review of the previous fire watch logs noted the record consisted of a single sheet and lacked the time, location, and staff name information when the tours were performed.. No additional documentation was provided at the time of survey to validate the fire watch procedure was performed in accordance to the applicable code. Interview with the Director of Maintenance verified the finding at the time of review. NFPA 101 - 2012 Edition 19.3.5 Extinguishment Requirements. 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 19.3.5.2 High-rise buildings shall comply with 19.4.2. 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1). 19.3.5.5 In Type I and Type II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered. Reference- Sprinkler 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 - 2010 Edition 15.5* Preplanned Impairment Programs. 15.5.1 All preplanned impairments shall be authorized by the impairment coordinator. 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner or designated representative. (4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b)*An approved fire watch (c)*Establishment of a temporary water supply (d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.”

“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: 42375 Based on observations and interviews the facility failed to ensure that all smoke barriers were able to resist the passage of smoke in accordance with the LSC, 2012 Edition 19.3.7.3 and 8.5.6.2. This deficient practice had the potential to affect all patients who reside within the hospital. Findings include: Observations during tour of the with the Director of Maintenance (DM) at 10:10 A.M. on 01/08/25 revealed smoke barriers not maintained in the second floor construction area. Pipe chases between floors that did not have active work being performed were not sealed between the occupied section and the area under construction. Interview with the DM verified the findings at the time of observation. NFPA 101-2012 Edition, Section 19.3.7.3 states, Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1.2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. NFPA 101-2012 Edition, Section 8.5.6.2 states, 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 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.”