Carrus Lakeside Hospital

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure: 1. Policy was followed for one (Patient #3) of four patients reviewed. 2. Medical Staff bylaws were followed for one (Patient #3) of four patients reviewed. 3. One set of Medical Staff bylaws for one (Carrus Lakeside Hospital) of one hospitals reviewed. POLICY and MEDICAL STAFF BYLAWS NOT FOLLOWED Review of the medical record for Patient #3 did not show documentation of pronouncement of death by a physician assistant or an attending or covering physician. Specifically: 1. A document titled “RELEASE OF BODY” read in part, “Patient pronounced by: [name withheld] APRN ...Date/Time: 3/17/2025 0943 [9:43 AM].” Review of a policy titled “Death Determination (including Brain Death) and Death Pronouncement” with a review date of 07/29/24 read in part, “Registered nurses employed by Carrus Hospitals may pronounce death for patients who are not on artificial means of life support or patients who are brain dead ...Note: Per the Medical Staff and Governing Board, a registered nurse or physician assistant may determine and pronounce a person dead in situations other than those described in #2 above.” Review of a document titled “MEDICAL STAFF BYLAWS RULES & REGULATIONS and POLICIES & PROCEDURES” adopted September 13, 2023 and restated August 12, 2024 read in part, “In the event of a Hospital patient death, the deceased shall be pronounced dead by the attending, or covering, physician or two hospital-employed Registered Nurses.” On 05/15/25 at 5:11 PM, Staff E reviewed the medical record and medical staff bylaws and stated: 1. They thought the bylaws were revised to include nurse practitioners when the hospital opened as Carrus. 2. Nurse practitioners or ED providers can pronounce patient death. 3. Registered nurses cannot pronounce patient death. ONE SET OF BYLAWS Review of two different sets of medical staff bylaws showed no change in the adoption date or the restated date. Specifically: 1. A document titled “MEDICAL STAFF BYLAWS RULES & REGULATIONS and POLICIES & PROCEDURES” was provided to the surveyor on 05/15/25 at 10:08 AM. It read in part, “Adopted September 13, 2023 Restated August 12, 2024...A-10. Hospital Death: In the event of a Hospital patient death, the deceased shall be pronounced dead by the attending, or covering, physician or two hospital-employed Registered Nurses.” 2. A document titled “MEDICAL STAFF BYLAWS RULES & REGULATIONS and POLICIES & PROCEDURES” was provided to the surveyor on 05/15/25 at 5:50 PM. It read in part, “Adopted September 13, 2023 Restated August 12, 2024...A-10. Hospital Death: In the event of a Hospital patient death, the deceased shall be pronounced dead by the attending, or covering, physician, advanced practice provider (NP or PA), or two hospital-employed Registered Nurses.” On 05/15/25 at approximately 6:15 PM, Staff B stated the hospital must have two versions of the medical staff bylaws.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure: 1. Provider notification for one (Patient #3) of four patients reviewed. 2. Congruent nursing documentation for one (Patient #3) of four patients reviewed. PROVIDER NOTIFICATION Review of the medical record for Patient #3 showed the patient had a heart rate of 120 and showed no documentation of physician notification by nursing. Specifically: 1. The Emergency Nursing Record read in part, “Triage Date 2/1/25 Time 1830 [6:30 PM] ...Vitals ...P [pulse] 120.” Tachycardia was circled to indicate positive for tachycardia. 2. The Emergency Physician Record at 8:28 PM showed: no checkmarked box to indicate nursing assessment reviewed or vitals reviewed; the fields for vital signs were blank; a checkmarked field for regular rate and rhythm with no rate indicated. 3. The Emergency Nursing Record read in part, “Discharge Vitals ...P [pulse] 130.” On 05/15/25 at 2:43 PM, Staff C reviewed the medical record and stated the nurse needed to notify the provider and they did not see where that was done. On 05/15/25 at 4:52 PM, Staff E reviewed the medical record and stated the provider was supposed to check the boxes showing nursing assessment and vital signs were reviewed. CONGRUENT DOCUMENTATION Review of the medical record for Patient #3 showed the patient had a heart rate of 120 and showed a normal cardiovascular system (CVS) assessment. Specifically: 1. The Emergency Nursing Record read in part, “Triage Date 3/16/25 Time 1212 [12:12 PM] ...Vitals ...P [pulse] 120.” The document showed CVS assessment with a checkmarked field for regular rate with no other rate indicated and showed a backslash through the word tachycardia to indicate negative for tachycardia. On 05/15/25 at approximately 2:56 PM, Staff C reviewed the medical record and stated they would expect tachycardia to be documented as positive for a heart rate of 120.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure correct timestamp for one (Patient #3) of four patient charts reviewed. Patient #3 Review of the medical record showed an EKG strip with a timestamp that did not coincide with the patient’s hospital visit. Specifically: 1. The Emergency Physician Record read in part, “DATE: 03/17/25 TIME SEEN: 0925 [9:25 AM] Reason [withheld].” 2. An EKG strip read in part, “08:44:14 [8:44 AM] 17-MAR-25 [03/17/25] [rhythm withheld].” (41 minutes before patient’s arrival to the hospital) On 05/15/25 at approximately 3:19 PM, Staff C reviewed the medical record and stated the time on the hospital’s EKG strip was not correct.”

“PERIODIC EQUIPMENT MAINTENANCE CFR(s): 482.26(b)(2) Periodic inspection of equipment must be made and hazards identified must be promptly corrected. This Standard is not met as evidenced by: 42140 Based on observation, record review and interview, the hospital failed to ensure equipment inspection prior to patient use for three (Patients #23-25) of 25 patients reviewed. On 03/25/25 from 9:26 AM to 9:58 AM, during a hospital tour, x-ray equipment was observed with a past due inspection sticker. Specifically: 1. A (name omitted) portable X-ray machine, model number 5140761-2 with a sticker that read in part, “ELECTRICAL SAFETY INSPECTION Month Due: Sept, Year Due: 2024.” Review of a radiology policy titled “Department Safety” read in part, “Preventative maintenance is performed on x-ray equipment on a regular basis by qualified service personnel and documented.” Review of X-ray reports showed receipt of X-ray from Carrus Lakeside Hospital for the following: 1. Patient #23 “RIGHT FOOT: 3 views Exam Date: 22-Jan-2025 9:10 AM” 2. Patient #24 “TWO VIEW CHEST Exam Date: 22-Jan-2025 9:22 AM” 3. Patient #25 “CXR 2V Exam Date: 21-Jan-2025 8:54 PM” On 03/25/25 from 9:26 AM to 9:33 AM, Staff A observed the past due electrical inspection sticker and stated: 1. The X-ray machine was a loaner they received from a rental company on 01/21/25. 2. The X-ray rental company was supposed to inspect the machine before delivering it. 3. They have used the loaner on patients. 4. A missed inspection posed the risk of patients receiving too much radiation exposure or an electrical issue. On 03/25/25 at 10:40 AM, Staff C stated the facility was responsible to ensure equipment received preventive maintenance. On 03/25/25 at 12:21 PM, Staff A stated: 1. They were checking with the X-ray rental company and the inspection appeared to have been missed. 2. They should have looked for a current inspection sticker when the machine was delivered. 3. The facility was placed on divert for X-ray equipment on 03/25/25 at 10:54 AM and would remain on divert until the X-ray rental company performed the inspection or provided documentation of a current inspection.”

“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: 42392 Based on record review and interview the hospital failed to ensure nursing staff initiated an individualized nursing care plan for two (Patients #6 and #13) of 20 patients. This failed practice has the likelihood to result in patients receiving poor quality of care and delayed therapeutic treatment. Findings: Patient #6 A review of patient records showed no individualized nursing care plan. Patient # 13 A review of patient records showed no individualized nursing care plan. On 03/26/2024, a review of a document titled “Care Plan-Nursing” stated “All patients will have a nursing care plan.” On 03/26/2024, at 2:30 pm, Staff A stated the appropriate nursing care plan for patient #6, and patient #13 was not in t/he patient chart.”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 42392 Based on record review and interview, the hospital failed to ensure completion of history and physical for two (Patient #12, and #13) of 20 patients. This failed practice has the likelihood to place patients at risk of receiving poor quality of care from uninformed medical care decisions by healthcare providers. A review of a document titled “Medical Staff Bylaws Rules and Regulations” read in part, A complete admission history and physical examination shall be completed and on the medical record within twenty-four (24) hours of admission... Findings: Patient #12 A review of a document titled “History and Physical Examination” showed no examination date. Patient #13 A review of a document titled “History and Physical” showed no examination date. On 3/27/2024, Staff A reviewed the medical record for patient #12 and #13 and stated the there was no way of knowing when the H&P was completed because the date of examination was not documented.”

“On 03/25/2024 a OSDH surveyor conducted an unannounced CMS initial certification survey at Carrus Lakeside Hospital located in Bristow, Oklahoma. An exit conference was conducted on 03/25/2024 with the Public relations Director, Director of Compliance, Human Resource Manager and Director of Plant Operations. Deficiencies were cited as a result of the survey. ***Note: Temporary Waiver Request A-1: NFPA 101 (2012) - 18.2.3.4 Aisles, Corridor and Ramps required for exit access in a hospital or nursing home shall be not less than 8ft. (2440mm) in clear and unobstructed width. The facility has requested that the existing 7’0” corridors be allowed temporarily until the new hospital can be built. Temporary waiver request A-1 is approved and valid until the end of the new hospital construction or a period of three years from the date of this letter (June 23, 2022), whichever comes first.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 NEW Buildings are to be protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state and local regulations prohibit sprinklers. Listed quick-response or listed residential sprinklers are used throughout smoke compartments with patient sleeping rooms. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed six square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 18.3.5.1, 18.3.5.4, 18.3.5.5, 18.3.5.6, 9.7, 9.7.1.1(1), 18.3.5.10 This Standard is not met as evidenced by: 12713 Based on observation and staff interview, the facility failed to provide sprinkler protection for 1 of 3 halls. Findings: 1. A tour of the facility was conducted on 03/25/2024, and the following observation was made: North Hall The electrical closet on the north hall was not sprinkler protected. 2. The maintenance supervisor was present during the tour of the facility and acknowledged the electrical closet was not sprinkler protected. Spinkler System - Installation 2012 NEW Buildings are to be protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state and local regulations prohibit sprinklers. Listed quick-response or listed residential sprinklers are used throughout smoke compartments with patient sleeping rooms. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed six square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 18.3.5.1, 18.3.5.4, 18.3.5.5, 18.3.5.6, 9.7, 9.7.1.1(1), 18.3.5.10”

“Smoking Regulations CFR(s): NFPA 101 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: 1. Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. 2. In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. 3. Smoking by patients classified as not responsible shall be prohibited. 4. The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. 5. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. 6. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This Standard is not met as evidenced by: 12713 Based on observations and staff interview, the facility failed to maintain and provide approved smoking equipment 1 of 1 outside smoking areas. Findings: 1. A tour of the facility was conducted on 03/25/2024 and the following observation was made: An outside smoking area was observed on the northeast side of the building. There was a open top coffee can being used as a ashtray. Also by the main entrance was a plastic smoke tower. An approved all-steel smoke tower or ashtrays were not provided for the safe disposal of the cigarette butts. 2. The maintenance supervisor was present during the tour of the facility and stated he would address the problems with the smoking and provide equipment in designated smoking areas as soon as possible.”