Mercy Hospital Marietta

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 12713 Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke located in 1 of 4 smoke compartments. Findings: 1. A tour of the facility was conducted on 11/15/23., and the following observation was made: a. The door to the patient supply closet had two holes where old hardware had been removed. This door would not resist the passage of smoke. 2. The maintenance supervisor was present during the tour of the facility and acknowledged the holes in the doors.”

“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: 12713 Based on observation and interview, the facility failed to maintain 3 of 4 smoke barrier walls to resist the passage of smoke. Findings: 1. A tour of the facility was conducted on 11/14/23, and the following observations were made. East, West and North wings smoke wall a) One unsealed penetration, associated with each smoke wall. A pipe chase for wires was ran through the smoke wall. Several types of wire were running through the pipe. Both ends of the pipe were open that would allow smoke to pass through. 2. The maintenance person was present when the smoke walls were observed on 11/14/23, and he acknowledged the unsealed penetrations to the smoke wall.”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(3) The CAH maintains a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. This Standard is not met as evidenced by: 41505 Based upon record review and interview, the hospital failed to ensure the list of contract services identified the service being provided and the scope of the service. Findings: Review of the list of contract services revealed only the name of the entity, the date it was renewed, and a termination clause was on the list. The actual service or scope of the service was not identified. Review of Contract R revealed the entity was to provide “certain health care services via telemedicine” and be responsible for credentialing and re-credentialing of providers. The contract failed to identify what actual service was being provided or the scope of the service. Interview on 11/06/23 at 2:50 p.m. with Staff F revealed the entity for this contract was to provide telemedicine for Neurology and confirmed the contract failed to identify this service. Review of Contract S revealed the entity was to provide tele-radiology services. According to Section 5 of the contract a quality indicator was to be used for (a) Reporting time within contract ranges. Further review of the contract revealed there were no contract ranges identified.”

“NUTRITION CFR(s): Nutrition (§483.25(g)(1) and (g)(2) of this chapter). “ §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (2) Is offered sufficient fluid intake to maintain proper hydration and health. This Standard is not met as evidenced by: 41505 Based upon record review and interview, the nutritional status for 3 of 8 swing bed patients (#2, #5, #6), failed to identify 1) an initial nutritional assessment (#2), and, 2) a reassessment of the patient’s nutritional status when changes were identified (#5, #6). Findings: Review of patient #2’s medical record revealed the patient was admitted to swing bed on 10/23/23 with a Stage II skin breakdown on the left gluteal. The dietary order was for sodium control, the body mass index was below normal, and the patient’s albumin was low at 2.7 (normal 3.4-5.0). Interview with Staff L on 11/8/23 at 10:05 a.m. revealed the patient’s appetite would “come and go” and she would experience nausea at times. Further review of the medical record revealed there failed to be documented evidence the Registered Dietician conducted a nutritional assessment. Review of patient #5’s medical record revealed the patient was admitted to acute care on 10/10/23 with Sepsis and was changed to swing bed status on 10/16/23. The patient had a Stage III decubitus, a high lactic acid level, a low Albumin level (2.4) and fever. The first dietary noted by the Registered Dietician was on 10/24/23 and identifed the skin breakdown and the need for an increase in protein intake. On 11/6/23 the patient’s Albumin level had again decreased to 2.2; however, there failed to be documentation the patient’s nutritional status was reassessed. Review of patient #6’s medical record revealed the patient was admitted to swing bed on 10/18/23 after having open heart surgery. The patient had surgical wounds from the surgery, a low albumin level (2.7) and was on a puree diet. Interview on 11/08/23 at 10:30 a.m. with Staff L revealed when the patient was admitted he was on a puree diet, which the patient did not like but since the diet was changed to chopped foods his appetite was better. The nursing staff implemented supplements (Glucerna) with ice cream. Further review of the medical record revealed the Registered Dietician conducted an initial nutritional assessment on 10/24/23 however no reassessment had been conducted when there changes made to his diet. Interview on 11/06/23 at 1:40 p.m. with Staff C revealed the Dietary Manager and the Registered Dietician conducted dietary evaluations, however, the manager was on medical leave and the Registered Dietician only visited every two weeks. There failed to be documented evidence a system was in place for patient nutritional evaluations when dietary personnel were not available.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 41505 Based upon record review and interview, the hospital failed to ensure an written transfer agreement was implemented for 3 of 4 Emergency Department Patients who required further in-patient psychiatric care (##12, #21, #22). This was evidenced by the failure to: 1) ensure a written transfer agreement was completed that stated the reason for the transfer and the risks and benefits associated with the transfer, 2) ensure the receiving facility had agreed to accept the transfer, and 3) the medical records (or copies) related to the patient’s emergency medical condition were provided to the receiving hospital. Findings: Patient #12 Review of patient #12’s Emergency Department (ED) record revealed on 07/28/23 this 31 year old female presented ambulatory to the ED with the chief complaint of Suicidal Ideation. Staff N conducted the medical screening exam and documented the following on the Medical Decision Making “Pt (patient) came to ED (Emergency Department) voluntarily, c/o (complaint of) suicidal thoughts and needing help. Patient was screened and found to have a UTI (Urinary Tract Infection) as well. She FaceTime with mental health from (Hospital Q) behavioral in Ardmore and placed at the same facility per (Staff M). Patient had a normal exam, Labs are within normal limits. She will be DC (Discharged) to Marietta Police for escort to (Hospital Q) in Ardmore. Pt (patient) is stable for transport.” Further review of patient #12’s ED record revealed there failed to be documented evidence a written transfer agreement was implemented to identify the risks and benefits of the transfer, that the receiving facility had accepted the patient, and medical records or copies were provided to the receiving facility. Patient #21 Review of patient #21’s ED record revealed on 09/24/23 this 60 year old male presented to the ED by EMS (Emergency Medical Services) with the chief complaint of Suicidal Ideation. Review of the History of Present Illness completed by Staff O revealed “60 year old male who presents via EMS from the casino with suicidal ideation stating that he will hang himself. Patient was seen yesterday in the ED at (Hospital T) for scrotal pain, he had workup and was started on antibiotic. Patient notes that he cannot take the antibiotic, that he cannot get it from the pharmacy as he has no money. He notes he is having defficulty urinating today because his foreskin is swollen. Patient is migrating north from Louisiana “I wanted to get away from my family”. He has decided to stay in Oklahoma. Tonight he called 911 for suicidal ideations. EMS notes that they were called several times today to patient and he noted he wanted a ride...” Staff O conducted further laboratory testing and medication administration and documented on the Medical Decision Making And Plan of Care “09/24/23, 12:58 a.m. (Hospital Q) will evaluate for EOD (Emergency Order of Detention)...Medically patient has anemia which appears to be chronic as it was on admit in Texas on 08/31/23 patient left that hospital stay AMA (Against Medical Advise) so no further workup was done. He currently denies any shortness of breath, fatigue or palpitations...” On 09/24/23 at 1:41 a.m. Staff O documented “patient is a candidate for EOD, awaiting (Hospital Q)” At 3:16 a.m. Staff O documented the patient was placed at Hospital Q in Ardmore for EOD. Further review of Patient #21’s ED record revealed there failed to be documented evidence an appropriate written a transfer agreement was implemented when the patient required further inpatient psychiatric care at another hospital. Patient #22 Review of patient #22’s Emergency Department Record revealed on 09/11/23 this 13 year old male presented to the Emergency Department with the chief complaint of Suicidal Ideation. Review of the History of Present Illness revealed Staff P documented “Patient is a 13 year old male with a known medical history of Major Depressive Disorder...that presents to the ED via POV (Private Vehicle) with c/c (chief complaint) of suicidal ideation. Mother is at bedside. Patient reports that SI has been present for the past few days. Denies having a plan, does report having access to means for self harm.” Review of the Medical Decision Making documented by Staff P revealed “(Entity V) consults completed. Nurse reports that patient needs to be inpatient. Nursing staff has sent plan of care to (Hospital U) for acceptance. Patient has been accepted to (Hospital U), state transport will take patient, waiting on state transport to pick patient up...report to RN at (Hospital U). Patient and mother have been updated on the transfer to (Hospital U). Mother and patient both voiced understanding. Advised patient and mother that now waiting on state transport, as soon as transport available will pick patient up.” Further review of Patient #22’s ED record revealed there failed to be documented evidence an appropriate written transfer agreement was implemented when the patient required further inpatient psychiatric care at another hospital. Interview on 11/08/23 at 12:30 p.m. with Staff C revealed the hospital used other entities (Hospital Q and Entity V) to conduct the psychiatric evaluation on their Emergency Department Patients. This was done by face time with the patient and the entity via telemedicine services. According to Staff C, these entities were responsible for determining if the psychiatric patient required in-patient or out-patient psychiatric care. After reviewing the Emergency Department Records for patients #12, #21 and #22, Staff C confirmed even though the psychiatric patient required further in-patient psychiatric care a written transfer agreement was not implemented and did not know why the EMTALA forms were not used.”