Atoka County Medical Center

“An unannounced Life Safety Code survey was conducted on 4/24/2025 at Atoka County Medical Center located in Atoka, OK. The facility was surveyed under NFPA 101, 2012 Edition, Existing and NFPA 99, 2012 Edition, Existing. The entrance conference was conducted on 4/24/2025 with the Director of Maintenance and Administrator. The facility was a one story building. The facility was fully sprinkler protected. Deficiencies were cited as a result of this survey. An exit conference was conducted on 4/24/2025 with the Administrator and the Director of Maintenance. The results of the survey were generally discussed and no other documentation was provided by the facility.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 46363 Based on observation and staff interview, the facility failed to ensure the kitchen deep fryer was properly separated from the open flames of the kitchen range as required by NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. This deficient practice had the potential to affect approximately 8 of 8 residents, who currently reside in the facility, as identified by the administrator on 4/24/2025. The facility had a census of 8 residents. Findings: 1. A tour of the facility was conducted on 4/24/2025 from 12:10 p.m. to 1:55 p.m., and the following observation was made: The deep fryer was located directly against the right side of the kitchen range. An eight inch high steel or tempered glass shield was not provided to separate the deep fryer from the surface flames of the kitchen range. 2. The Director of Maintenance was present during the tour of the facility and acknowledged the deep fryer was not separated from the kitchen range surface flames. NFPA 96, 1998 Edition, 9-1.2.3 states: All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment. Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance.”

“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 staff interview, the facility failed to assure the minimum required number of fire drills were conducted within the past year. This had the potential to affect 8 of 8 residents, who currently resided in the facility, as identified by the administrator on 4/24/2025. The facility had a census of 8 residents. Findings: 1. Review of the facility fire drill reports was conducted on 4/24/2025 at 11:20 p.m. There was no documentation the facility had conducted a fire drill for the following shift: *Second shift for the first quarter of 2025. 2. The Director of maintenance was interviewed during the record review and he stated he could not find the missing the fire drill. Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least once a quarter for each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 50779 Based on observation, record review and interview, the facility failed to ensure crash carts were prepared for use for one ( Medical/Surgical Floor crash cart ) of one crash carts. Findings: On 02/27/25 at 9:45 AM during a tour of the facility, the Medical/Surgical Floor crash cart was observed to be missing the PM check off on 02/26/25. A review of policy “ Emergency Crash Cart Security and Accountability” stated in part, “ the nursing staff shall visually inspect the numbered lock located on the emergency crash cart at every change of shift, documenting the cart is properly locked and all appropriate contents are present and intact.” On 02/27/25 at 9:45 AM, Staff J stated the evening check off on 02/26/25 was missed and all crash carts are supposed to be checked every 12 hours or once a shift (day and night).”

“ROUTINE STORAGE AND DISPOSAL OF TRASH CFR(s): (2) There is proper routine storage and prompt disposal of trash; This Standard is not met as evidenced by: 50779 Based on observation and interview, the facility failed to ensure molded fruit was removed from one (Atoka County Medical Center) of one kitchen. Findings: On 02/27/25 at 10:30 AM during a tour of the facility, a molded lemon was observed in a fruit bin in the kitchen. On 02/27/25 at 10:30 AM Staff A stated that the molded lemon should not be in the bin. On 02/28/25 at 2:00 PM, Staff C, stated the fruit bins are to be checked every day and that spoiled or molded fruit should be thrown away when found.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 50779 Based on record review and interview, the hospital failed to ensure: 1. Initiation of the nursing care plans for 15 (Patients #1 - #15) of 15 patients reviewed. 2. Completion of the initial nursing assessment for three (Patients #12 - #14) of 15 patients reviewed. Findings: NURSING CARE PLAN: A review of policy titled “ Care Plan - Swingbed” read in part, “Atoka Medical Center shall provide an organized written plan, which shall promote both quality and continuity of care.” A review of policy titled “Care Plan - Nursing” read in part, “ the admission care plan will be initiated by the RN and will be used as a guide for care until discharged or goals are met. “ A review of the medical records showed the following: 1. Patient #1 had a hospital stay from 02/23/22 to 03/03/22 and had no documented nursing care plan for eight days. 2. Patient #1 had a hospital stay from 04/05/22 to 05/05/22 and had no documented nursing care plan for 30 days. 3. Patient #2 had a hospital stay from 09/11/23 to 09/12/23 and had no documented nursing care plan for one day. 4. Patient #3 had a hospital stay from 10/11/23 to 10/15/23 and had no documented nursing care plan for four days. 5. Patient #4 had a hospital stay from 12/12/23 to 12/14/23 and had no documented nursing care plan for two days. 6. Patient #5 had a hospital stay from 12/26/23 to 12/30/23 and had no documented nursing care plan for four days. 7. Patient #6 had a hospital stay from 05/25/22 to 05/28/22 and had no documented nursing care plan for three days. 8. Patient #7 had a hospital stay from 06/02/22 to 06/05/22 and had no documented nursing care plan for three days. 9. Patient #8 had a hospital stay from 06/26/22 to 06/30/22 and had no documented nursing care plan for four days. 10. Patient #10 had a hospital stay from 08/26/23 to 09/12/23 and had no documented nursing care plan for 17 days. 11. Patient #11 had a hospital stay from 10/05/23 to 10/16/23 and had no documented nursing care plan for 11 days. 12. Patient #12 had a hospital stay from 11/08/23 to 11/15/23 and had no documented nursing care plan for seven days. 13. Patient #13 had a hospital stay from 12/15/23 to 12/22/23 and had no documented nursing care plan for seven days. 14. Patient #14 had a hospital stay from 10/17/22 to 10/28/22 and had no documented nursing care plan for 11 days. 15. Patient #15 had a hospital stay from 11/29/22 to 12/15/22 and had no documented nursing care plan for 16 days. On 02/28/25 at 10:00 AM, Staff B stated there were supposed to be nursing care plans for each patient, but they were unable to locate them in the medical record. INITIAL NURSING ASSESSMENTS: A review of policy “Assessment-Reassessment” read in part, “all patients will have the initial nursing assessment completed within a maximum of four hours of the patient’s arrival to the unit.” 1. Patient #12 - Review of the medical record showed a 11/08/23 to 11/15/23 hospital stay and showed no documented initial nursing assessment (> 168 hours past due). 2. Patient #13 - Review of the medical record showed a 12/15/23 to 12/22/23 hospital stay and showed no documented initial nursing assessment (> 168 hours past due). 3. Patient #14 - Review of the medical record showed a 10/17/22 to 10/28/22 hospital stay and showed no documented initial nursing assessment for (> 264 hours past due). On 02/28/25 at 2:30 PM, Staff B stated that all patients were to have an initial nursing assessment at admission and that the initial nursing assessments were missing on patients #12, #13, and #14.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50779 Based on observation and interview, the facility failed to ensure limited exposure to bloodborne pathogens for one (Emergency Room 2 ) of five emergency rooms. Findings: On 02/27/25 at 10:30 AM during a tour of the facility, an open sharps container was observed sitting on the floor and was observed to be half filled with exposed needles, instruments, scissors, and blood tubes. On 02/27/25 at 10:30 AM, Staff A stated that this has been a problem in the Emergency Room and the sharps container was not supposed to be open on the floor.”