Cimarron Memorial Hospital

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 42140 Based record review and interview, the hospital failed to ensure record of emergency room visit for one (Patient #19) of 20 patient records reviewed. This failed practice had the likelihood to result in no means to reference patient care or disposition for all emergency room patients. Findings: Patient #19 Review of a document titled “ER Log Report 03/01/2025-08/31/2025” showed no visit entry for the patient on 07/08/25. Review of policy titled “Emergency Room EMTALA-Central Log” approved 12/23/24 read in part, “The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance...whether he or she left before a medical screening examiniation...whether he or she refused treatment...The Central Log...must contain, at a minimum, the name of the individual.” On 09/02/25 at 10:40 AM, Staff K stated the patient was taken to Cimarron Memorial Hospital ED on 07/08/25 around 9:00 PM and the patient was not checked in. On 09/04/05 at 2:20 PM, Staff H stated they remembered the patient and the patient came to the ED at about 9:30 PM a few weeks prior. On 09/04/25 at 2:44 PM, Staff B reviewed the hospital’s electronic medical record system and stated there was no record for the patient on 07/08/25. On 09/04/025 from 3:29 PM to 3:38 PM , Staff I stated: 1. They were working at the hospital on 07/08/25. 2. They remembered the patient. 3. Every patient who came the ED was to be entered onto the ER log. On 09/04/25 at 5:38 PM, Staff J stated: 1. They remembered the patient. 2. They did not know if they formally checked the patient in. 3. They did not think they put the patient in the system.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure documentation of medical screening exam for one (Patient #19) of 20 patient records reviewed. This failed practice had the likelihood to result in no means to reference a determination of an emergency medical condition. Findings: Patient #19 Review of the hospital’s electronic medical record system showed no documentation of an ED visit on 07/08/25 and showed no documentation the patient received a medical screening exam. Review of policy titled “EMTALA-Medical Screening and Stabilization” approved 12/23/24 read in part, “A hospital must provide an appropriate MSE ...to determine whether or not an EMC exists ...to any individual...who requests such an examination...The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.” On 09/02/25 at 10:40 AM, Staff K stated the patient was taken to Cimarron Memorial Hospital ED on 07/08/25 around 9:00 PM to see if the patient was concussed. On 09/04/25 from 2:20 PM to 3:05 PM, Staff H stated: 1. The patient was bucked off a horse and had been dazed prior to coming to the ED. 2. They performed a routine medical screening exam that included Glasgow Coma Scale. 3. They offered to send the patient to another facility out of caution as no radiology service was available. 4. The patient’s mother decided to wait and see how the patient did overnight. 5. No documentation of the ED visit could be found. 6. They were not really familiar with EMTALA, but had heard of it. On 09/04/25 at 2:44 PM, Staff B reviewed the hospital’s electronic medical record system and stated there was no record for the patient on 07/08/25.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 12713 Based on record review and interview, the facility failed to review and update the emergency preparedness plan annually. Findings: 1. The facility records were reviewed 01/15/2025. The CEO provided an emergency preparedness policy binder. The policy had not been reviewed and updated in the last 12 months. 2. The CEO was interviewed on 01/15/2025 and he stated he had not updated the emergency preparedness book yet.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 12713 Based on observation and interview the facility failed to ensure egress doors could be opened with one action as required. Findings: On 01/15/2025 the surveyor observed a dead bolt lock on patient room #5 and #7. These dead bolt locks required a key to unlock the door from the inside of the room. The CEO was present when the dead bolts were observed on the patient room doors. He stated he would have the dead bolts removed as soon as possible.”

“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: 12713 Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system quarterly. Findings: 1. The facility records were reviewed on 01/15/2025. The most recent annual sprinkler inspection document was dated 09/17/2024. The quarterly sprinkler inspections should have been performed in the first, second and fourth quarter of 2024. There was no documentation for the missing quarterly sprinkler inspections. 2. The CEO was present during the record review on and stated he was not aware the quarterly sprinkler inspections had not been done.”

“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: 12713 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. Findings: 1. Review of the facility fire drill reports was conducted on 01/15/2025. There was no documentation the facility had conducted a fire drill for the following shift: a. the first and second shifts for the first quarter of 2024. b. the first and second shifts for the second quarter of 2024. 2. The CEO was interviewed on 01/15/2025 and stated the facility missed the fire drill for those shifts.”

“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: 12713 Based on record review and interview, the facility failed to conduct the routine inspections of the corridor doors throughout the facility. Findings: 1. The facility records were reviewed on 01/15/2025 and no documentation was found to show the facility had conducted routine corridor door and smoke door inspections. 2. The CEO was interviewed during the record review and he stated he was not aware of the corridor door and smoke door inspections. 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)”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 12713 Based on record review and interview the facility failed to ensure the building system risk assessments were completed. Findings: Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessments were not completed and do not exist. On 01/15/2025 the surveyor asked the CEO for the EES and Medical Gas building system risk assessments. She stated they were not aware of the requirement but would ensure they will be completed.”

“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: 12713 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. Findings: 1. During the record review on 01/15/2025 there was no documentation the facility has been performing an weekly visual check and a monthly 30 minute generator test. 2. The CEO was interviewed on 01/15/2025, and stated he did not have documentation of the generator weekly and monthly test.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 50779 Based on observation and interview, the hospital failed to ensure expired drugs and biologicals were discarded and no longer in use for all patients. Findings: During an observation on 09/11/2024 at 10:00 am, the below listed items were observed to be expired: 1. Sodium Chloride inhalation solution expired 03/2024 2. Prochlorperazine Edisylate expired 08/2024 During an interview with Staff #1 on 09/11/2024 at 10:00 am, Staff 1 stated the staff should be checking for expired supplies and the sodium chloride and prochlorperazine edisylate were expired.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 50779 Based on a review of records and interview, the hospital failed to update their policies and procedures for all patients and staff. Findings: A review of administrative documents showed the following policies and procedures last reviewed on: 1. EMTALA-Medical Screening Policy last updated 2005 2. EMTALA Central Log Policy last updated 2005 3. EMTALA Stabilization Policy last updated 2005 4. EMTALA Transfer Policy last updated 2005 5. Precipitous Delivery Policy last updated 2005 On 09/11/2024 at 3:00 pm, Staff I, H and K stated: 1. the hospital failed to update their policies and procedures timely and 2. there was no policy on how often policies should be reviewed and updated.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 50779 Based on a review of records and interview, the facility failed to ensure the accuracy, legibility and completeness of the medical record for one (Pt # 2) of twenty records. Findings Pt #2 A review of the medication orders showed instructions to: 1. Give Demerol 50 (g or mg) illegible 2. Give pheno... illegible 50 (g or mg) illegible Documentation showed no date, time, or route, no evidence if the orders were verbal or written orders, no verification that the orders were verified by the nurse, and no signature or time by the ordering provider. On 09/12/2024 at 2:20 pm, Staff H stated: 1. The hospital failed to ensure the Accuracy, Legibility and Completeness of the medical record.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (1) Be appropriate for the complexity of the CAH’s organization and services provided. This Standard is not met as evidenced by: 50779 Based on a record review and interview, the hospital failed to ensure their QAPI program contained measures for patient care and satisfaction for 20 (Pt 1-20) of 20 patients review reviewe, potentially affecting all patients and staff. Findings: A review of QA records showed no periodic review of all services provided, no review of medication errors, and no review of patient care, and no review of patient satisfaction. On 09/12/24 at 240 pm, Staff H, I, J stated the QA records showed no documentation related to patient care or patient satisfaction.”