Pushmataha Hospital

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 46363 Based on record review and interview, the facility failed to perform required testing on emergency lights throughout the facility. This practice had the potential to affect 12 of 12 residents who currently resided in the facility, as identified by the director of nursing on 06/10/26. Findings: On 06/10/26 from 10:00 p.m. to 11:30 p.m., the facilities maintenance records were reviewed, and no monthly or annual testing documentation on the emergency lights were found from June 2025 through June 2026. On 06/10/26 from 10:00 p.m. to 11:30 p.m., the maintenance supervisor was interviewed and acknowledged they could not provide documentation the emergency lights had been tested monthly or annually.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 46363 Based on record review and interview, the facility failed to perform required testing on exit signs throughout the facility. This practice had the potential to affect 12 of 12 residents who currently resided in the facility, as identified by the director of nursing on 06/10/26. Findings: On 06/10/26 from 10:00 p.m. to 11:30 p.m., the facilities maintenance records were reviewed, and no monthly or annual testing documentation on the exit signs were found from June 2025 through June 2026. On 06/10/26 from 10:00 p.m. to 11:30 p.m., the maintenance supervisor was interviewed and acknowledged they could not provide documentation the exit signs had been tested monthly or annually.”

“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: 46363 Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system. This deficient practice had the potential to affect 12 of 12 residents who currently resided in the facility, as identified by the director of nursing on 06/10/26. Findings: On 06/10/26 from 10:00 a.m to 11:30 a.m., the facilities maintenance records were reviewed, and no quarterly sprinkler inspection reports were found from June 2025 through June 2026. On 06/10/26 from 10:00 a.m to 11:30 a.m., the maintenance supervisor was interviewed and acknowledged no quarterly sprinkler inspections were performed.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 46363 Based on record review and interview, the facility failed to perform required fire alarm drills. This practice had the potential to affect 12 of 12 residents who currently resided in the facility, as identified by the director of nursing on 06/10/26. Findings: On 06/10/26 from 10:00 p.m. to 11:30 p.m., the maintenance records were reviewed and the facility failed to perform quarterly fire drills for the 2nd shift from June 2025 through June 2026. On 06/10/26 from 10:00 p.m. to 11:30 p.m., the maintenance supervisor was interviewed and acknowledged they had not conducted fire drills for the 2nd shift from June 2025 through June 2026.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 46363 Based on record review and interview, the facility failed to perform required inspections of corridor doors on the path of egress. This practice had the potential to affect 12 of 12 residents who currently resided in the facility, as identified by the director of nursing on 06/10/26. Findings: On 06/10/26 from 10:00 p.m. to 11:30 p.m., the facilities maintenance records were reviewed, and no documentation for routine corridor door inspections was found. On 06/10/26 from 10:00 p.m. to 11:30 p.m., the maintenance supervisor was interviewed and acknowledged there was no documentation of corridor door inspections.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 46363 Based on record review and interview, the facility failed to perform required annual inspection on the oxygen storage and lines. This practice had the potential to affect 12 of 12 residents who currently resided in the facility, as identified by the director of nursing on 06/10/26. Findings: On 06/10/26 from 10:00 p.m. to 11:30 p.m., the facilities maintenance records were reviewed, and the last inspection of the oxygen storage and lines was last performed on 03/21/25. No inspection report was found from June 2025 through June 2026. On 06/10/26 from 10:00 p.m. to 11:30 p.m., the maintenance supervisor was interviewed and acknowledged the oxygen inspection had not been performed from June 2025 through June 2026.”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 41506 Based on record review and interview, the hospital failed to conduct at least one annual Performance Improvement Project for 2024 and 2025 based on the scope and complexity of the types of services furnished by the hospital identifying a problem in a targeted area and resulting in improved patient health outcomes and safety and failed to have a Performance Improvement Project in place for 2026. Findings: A review of the Quality Assessment and Performance Improvement Program manual showed no evidence of a Performance Improvement Project conducted for 2024 and 2025 or a Performance Improvement Project in place for 2026. On 05/05/26 at 2:30 p.m. Staff C stated the hospital’s Quality Assessment and Performance Improvement Program had not conducted any Performance Improvement Projects for 2024 or 2025 and they did not have a Performance Improvement Project in place for 2026. They stated the QAPI program was not conducting Performance Improvement Projects and they were not aware of this regulation.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 41506 Based on record review and interview, the hospital failed to ensure the nursing staff developed a nursing care plan for each patient based on assessing all the patient’s nursing care needs and not solely those needs related to the admitting diagnosis for three (Patient #1, #2, #3) of three patients whose medical records were reviewed for nursing care plans out of 20 medical records reviewed. Findings: A review of Patient #1 medical record documented in part, Patient #1 was admitted to the hospital with a diagnosis of dehydration. A review of the patient’s medical history revealed the patient also had a present history of bronchitis and hypertension. The care plan showed the patient only had a documented care plan with goals and treatment plans for falls, infection, and fluid management. A further review of the nursing care plan and the medical record revealed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses of bronchitis and hypertension. A review of Patient #2 medical record documented in part, Patient #2 was admitted to the hospital with a diagnosis of unresponsiveness. A review of the patient’s medical history revealed the patient also had a present history of diabetes and hypertension. The care plan showed the patient only had a documented care plan with goals and treatment plans for respiratory function and falls. A further review of the nursing care plan and the medical record revealed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses of diabetes and hypertension. A review of Patient #3 medical record documented in part, Patient #3 was admitted to the hospital with a diagnosis of weakness and shortness of breath. A review of the patient’s medical history revealed the patient also had a present history of hypertension and gastric reflux. The care plan showed the patient only had a documented care plan with goals and treatment plans for respiratory function and falls. A further review of the nursing care plan and the medical record revealed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses of hypertension and gastric reflux. A review of the hospital policy titled “Care Planning,” approved in 2026, read in part, “Care plans will be implemented through the integration of assessment findings ...The plan of care shall be individualized, based on diagnosis, patient assessment, and personal goals of the patient.” On 05/05/26 at 12:15 p.m. Staff B stated the nurses were supposed to develop care plans based on all a patient’s diagnoses and assessments. On 05/05/26 at 12:55 p.m. Staff N stated the nurses developed the patient care plans based mostly on the admitting diagnoses and care plans were usually not developed for all the patient’s current diagnoses.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 41506 Based on record review and interview, the hospital failed to ensure that nursing services were provided in accordance with hospital policy by failing to annually evaluate and reassess the Skills Competency of staff or conduct Performance Evaluations on 12 (Staff D, F, G, I, J, K, L, M, N, O, Q, S) of 12 staff employees out of 14 staff employee files reviewed for 2024 and 2025 and failing to have a Skills Competency or a Performance Evaluation process in place for 2026. Findings: A review of employee files for Staff D, F, G, I, J, K, L, M, N, O, Q, S showed no documentation of a Skills Competency for these employees in 2024 and 2025 to reassess that the staff had the appropriate qualifications/skills for the tasks they were required to perform. The same employee files showed no documentation of a Performance Evaluation for 2024 or 2025. A review of the hospital policy titled “Performance Improvement,” approved in 2026, read in part, “All employees shall complete a (annual) skills checklist pertinent to their job description ...to demonstrate current clinical competence ...Employees will be evaluated on an annual basis by their supervisor on their job performance and their quality of care rendered.” On 05/06/26 at 10:45 a.m. Staff B and Staff E stated the hospital did not have a Skills Competency Checklist or a Performance Evaluation form in place. They stated annual Skills Competencies and Performance Evaluations were not being conducted. Staff B stated the hospital used to have these forms and were conducting annual Skills Competencies and Performance Evaluations, but the process “fell by the wayside.””

“QUALIFIED STAFF CFR(s): 482.26(c)(2) Only personnel designated as qualified by the medical staff may use the radiologic equipment and administer procedures. This Standard is not met as evidenced by: 41506 Based on record review and interview, the hospital failed to ensure radiological services provided by the hospital were provided by personnel who were qualified to use the radiologic equipment when performing patient diagnostic studies, according to hospital policy, for three (Staff I, Q, S) of three staff employed by the hospital as Radiology Technicians. Findings: A review of the hospital policy titled, “RT and CT Technologist,” updated 05/06/2022, read in part, “Education and Experience Required: Graduate of an accredited Radiologic Technology program, ARRT registered, or registry eligible, or hold a certificate in Radiology. On 05/04/26 at 2:00 p.m. Staff I stated they were the Radiology Supervisor and they, along with 2 (two) other staff (Staff Q and S), perform diagnostic radiologic x-rays (routine x-rays and CT scans) on hospital patients. Staff I stated the radiology staff were not registered Radiology Technicians, but a contract registered Radiology Technician had evaluated their competencies. On 05/05/26 at 10:45 a.m. Staff E stated the policy “RT and CT Technologist,” updated 05/06/2022, was the most current policy. They stated the radiology staff (Staff I, Q, and S) were not Registered Radiology Technicians nor did they hold a certificate in Radiology, according to their employee files. They were not sure if Oklahoma required ARRT or a radiology certificate for radiology staff.”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 41506 Based on record review and interview, the hospital failed to ensure the Infection Control Officer maintained on-going education, training, or courses in the principles and methods of infection control to oversee the Infection Control Program. Findings: A review of the employee file for Staff C showed they were the Infection Control Officer. Their employee file showed no documented evidence of on-going education or courses in the principles and methods of infection control to maintain competency as the Infection Control Officer for the hospital’s Infection Control Program. On 05/05/26 at 1:30 p.m. Staff C stated they had no additional training or on-going education or courses in the principles and methods of infection control since their initial orientation in 2016.”