Prague Regional Memorial Hospital

“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. Findings: 1. A tour of the facility was conducted on 08/07/2024 from 2:00 p.m. to 3:55 p.m., and the following observation was made: The deep fryer was located directly against the left 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 maintenance supervisor 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.”

“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: 46363 Based on observation and staff interview, the facility failed to maintain ceilings and walls to resist the passage of smoke. Findings: 1. A tour of the facility was conducted on 08/07/2024 from 2:00 p.m. to 3:55 p.m., and the following observations were made: a. 2 unsealed ceiling penetrations were observed in the kitchen. b. 2 unsealed wall penetrations were observed in x-ray hall by the electrical box and time clock. c. An unsealed wall penetration was observed in the fire wall above the fire doors leading into the clinic area. d. An unsealed ceiling penetration was observed near the ER registration desk. e. An unsealed ceiling penetration was observed in the public bathroom. f. 2 unsealed penetrations were observed in the supply closet located on the ER central hall. 2. The maintenance supervisor was present during the tour of the facility and acknowledged the problems with the unsealed areas. He stated he would make the repairs as soon as possible.”

“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: 46363 Based on observation and interview, the facility failed to enforce required smoking regulations. Findings: 1. A tour outside of the facility was conducted on 08/07/2024 from 2:00 p.m. to 3:55 p.m., and it was observed that the generator did not have a required no smoking sign on it. 2. The maintenance supervisor and administrator were present during the tour and acknowledged that there was not a no smoking sign and stated he would put one up asap.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 46363 Based on record review, observation, and staff interview, the facility failed to properly maintain and test the generator as required by NFPA 99. In the event of an electrical outage, the facility could not be assured the generator would power the designated outside lights for safe evacuation during an emergency. Findings: 1. During the record review of the generator on 08/07/2024 at 1:00 p.m., it was determined there was no documentation the maintenance supervisor was performing an weekly inspection on the generator. 2. The maintenance supervisor was interviewed and stated he tested the generator monthly but was unaware that a weekly visual inspection was to be performed and documented.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 46363 Based on observation and staff interview, the facility failed to provide safe storage for each oxygen cylinder as required by NFPA 99. Findings: 1. During a tour of the facility on 08/07/2024 from 2:00 p.m. to 3:55 p.m., the following observations were made: There were no empty or full oxygen bottles signs. The full and empty bottles were also mixed together. 2. The maintenance supervisor was present during the tour of the facility on and acknowledged the oxygen cylinders were not labeled and were mixed together.”

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 41506 Based on observation the CAH (Critical Access Hospital) failed to ensure the dedicated Emergency Room had a notice posted conspicuously in a place(s) likely to be noticed by all individuals entering the dedicated Emergency Department, indicating that the CAH does not have a MD (Doctor of Medicine) or a DO (Doctor of Osteopathy) present in the CAH 24 hours per day, 7 days per week. Findings: An observation on 06/17/24 at 3:00 p.m., with Staff C, revealed the posted notice indicating the dedicated Emergency Department did not have a MD (Doctor of Medicine) or a DO (Doctor of Osteopathy) present in the CAH 24 hours per day, 7 days per week was not posted in a conspicuous place likely to be noticed by all individuals entering the dedicated Emergency Department, as evidenced by the posted notice being posted on the top right corner of a “busy” bulletin board with at least 16 other posted notices of the same size. The bulletin board was located in a hallway outside of the Emergency Department’s patient rooms. In an interview on 06/17/24 at 3:00 p.m. Staff C indicated she did not think there was another notice posted anywhere else in the Emergency Department.”

“RADIOLOGY SERVICES CFR(s): §485.635(b)(3) Radiology services. Radiology services furnished by the CAH are provided by personnel qualified under State law, and do not expose CAH patients or personnel to radiation hazards. This Standard is not met as evidenced by: 41506 Based on record review and interview the CAH failed to ensure all radiological services provided by the facility, (according to CMS 485.635(b)(3) and the CAH policy) was provided by personnel qualified under state law in accordance with acceptable standards of practice which include maintaining compliance with appropriate federal and state laws, regulations, and guidelines governing radiological services, including certification requirements by nationally recognized professional radiological organizations, as evidenced by no documented evidence that the radiology technician/supervisor (Staff E) was a graduate of an accredited radiological technology program or currently enrolled in an accredited radiological technology program or that the radiology technician was ARRT (American Registered Radiologic Technologist). Findings: A review of the hospital policy titled, “Radiology Services and Staff”, as provided by administration as a current policy, revealed in part: Personnel Qualifications- Graduate of an accredited or recognized radiologic technology program, or currently enrolled in an accredited radiologic technology program, or ARRT registered and in compliance with continuing education credits. A review of the hospital policy titled, “Radiology Supervisor”, as provided by administration as a current policy, revealed in part: Minimum Qualifications- Education and /or Experience: Associates of Applied Science in Radiology, ARRT or State License or equivalent is required. Licensure/Certification: Current Oklahoma Registry, ARRT or State License or equivalent is required. A review of the employee file for Staff E, with Staff C and Staff D, revealed no documented evidence that Staff E was ARRT registered or was a graduate of an accredited or recognized radiologic technology program, or currently enrolled in an accredited radiologic technology program, In an interview on 6/20/24 at 11:45 a.m. Staff E indicated she was the Radiology Supervisor and her duties involved performing diagnostic radiologic x-rays on patients, to include routine x-rays and CT (computed tomography) scans. Staff E indicated she was not a graduate of an accredited or recognized radiologic technology program, or currently enrolled in an accredited radiologic technology program. She further indicated she was not ARRT registered and her experience was based on “on the job” training.”

“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: 41506 Based on record review and interview the CAH 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 4 of 4 (Patient #14, #15, #16, #17) inpatient medical records reviewed for nursing care plans. Findings: A review of Patient #14 medical record revealed in part: Patient #14 was admitted to the hospital as an inpatient on 01/13/24 with a diagnosis of acute respiratory failure. A review of the patient’s medical history revealed the patient also had a present history of atrial fibrillation, hypertension, neuropathy, and gastric reflux. A review of the care plan revealed the patient only had a documented care plan with goals and treatment plans relating to the admitting diagnosis. A further review of the nursing care plan revealed no documented evidence that the patient’s care plan goals and treatments had nursing care needs developed for atrial fibrillation, hypertension, neuropathy, and gastric reflux. A review of Patient #15 medical record revealed in part: Patient #15 was admitted to the hospital on 02/11/24 with a diagnosis of shortness of breath. A review of the patient’s medical history revealed the patient also had a present history of delusions, dementia, anxiety, and vitamin B deficiency. A review of the current care plan revealed the patient only had a documented care plan with goals and treatment plans relating to the admitting diagnosis. A further review of the nursing care plan revealed no documented evidence that the patient’s care plan goals and treatments had nursing care needs developed for delusions, dementia, anxiety, and vitamin B deficiency. A review of Patient #16 medical record revealed in part: Patient #16 was admitted to the hospital on 01/24/24 with a diagnosis of a closed ankle fracture. A review of the patient’s medical history revealed the patient also had a present history of atrial fibrillation, depression, hypertension, and diabetes. A review of the care plan revealed the patient only had a documented care plan with goals and treatment plans relating to the admitting diagnosis. A further review of the nursing care plan revealed no documented evidence that the patient’s care plan goals and treatments had nursing care needs developed for atrial fibrillation, depression, hypertension, and diabetes. A review of Patient #17 medical record revealed in part: Patient #17 was admitted to the hospital on 03/16/24 with a diagnosis of altered mental status. A review of the patient’s medical history revealed the patient also had a present history of gout, hyponatremia, and hypertension. A review of the current care plan revealed the patient only had a documented care plan with goals and treatment plans relating to the admitting diagnosis. A further review of the nursing care plan revealed no documented evidence that the patient’s care plan goals and treatments had nursing care needs developed for gout, hyponatremia, and hypertension. A review of the hospital policy titled, “Nursing Care Plans”, provided by administration as a current policy, revealed in part: The nursing care plan is based on assessing the patient’s nursing needs to include; treatment goals, nursing interventions, on-going assessments and revisions, and discharge planning (and not solely those needs related to the admitting diagnosis). In an interview on 06/20/24 at 3:30 p.m. Staff I indicated the nurses routinely developed the patient’s care plans based only on the admitting diagnoses and care plans were not developed for all the patients’ current diagnoses upon admit.”

“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: 41506 Based on observation, record review, and interview the CAH failed to ensure a functional and sanitary environment according to acceptable professional standards of practice relating to infection control as evidenced by observation of infection control breaches: 1) failing to ensure staff sanitized their hands after removing their gloves, 2) failing to ensure the dietary staff did not use patient serving trays as cutting/chopping boards for raw meats and other cutting tasks, and 3) failing to ensure expired sutures were not available for patient use. Findings: 1) failing to ensure staff sanitized their hands after removing their gloves, In observations on 06/20/24 from 9:30 a.m. to 10:30 a.m., in the presence of Staff C, Staff J and Staff K did not sanitize their hands after removing their gloves after performing patient care tasks and before moving to other patient care tasks. A review of the CDC Guideline for Hand Hygiene in Health-Care Settings, revealed in part: Gloves do not provide complete protection against hand contamination. Pathogens presumably gain access to the caregiver’s hands via small defects in gloves. One study found that health care workers who wore gloves during patient contact contaminated their hands more often than those who did not wear gloves. In published studies, the barrier integrity of gloves varies on the basis of type and quality of glove material, intensity of use, length of time used, manufacturer, whether gloves were tested before or after use, and method used to detect glove leaks. HICPAC (Healthcare Infection Control Practices Advisory Committee) Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: “ Immediately before touching a patient “ Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices “ Before moving from work on a soiled body site to a clean body site on the same patient “ After touching a patient or the patient’s immediate environment “ After contact with blood, body fluids, or contaminated surfaces “ Immediately after glove removal In an interview on 06/20/24 at 10:45 a.m. Staff C confirmed Staff J and K did not sanitize their hands after removing their gloves after performing patient care tasks and before moving to other patient care tasks. 2) failing to ensure the dietary staff did not use patient serving trays as cutting/chopping boards for raw meats and other cutting tasks, An observation on 06/17/24 at 3:00 p.m. of some of the patient serving trays in the Dietary Department revealed they were scratched and had small cracks in the trays preventing effective disinfection. In an interview on 06/17/24 at 3:00 p.m. Staff H indicated the Dietary Department did not have cutting/chopping boards and the dietary personnel were using patient serving trays as cutting/chopping boards to cut and chop meats and other food items. Staff H indicated serving trays was probably not intended for cutting and chopping foods and could harbor bacteria. 3) failing to ensure expired sutures were not available for patient use. An observation on 06/17/24 at 3:30 p.m. in the Emergency Department supply room revealed a box of sutures that had expired on 05/31/21. In an interview on 06/17/24 at 3:30 p.m. Staff C indicated supplies are checked periodically by staff for outdated supplies and the expired box of sutures should have been discarded.”