Mercy Hospital Logan County

“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 2 of 5 smoke compartments. Findings: 1. A tour of the facility was conducted on 04/11/25., and the following observations were made: a. The CT scan room door had old hardware that had been removed leaving two hole in the door for smoke to pass through. b. The quality improvement office door had old hardware that had been removed leaving two hole in the door for smoke to pass through. c. The respiratory therapy office door had old hardware that had been removed leaving two hole in the door for smoke to pass through. 2. The maintenance person 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 7 smoke barrier walls to resist the passage of smoke. Findings: 1. A tour of the facility was conducted on 04/11/25, and the following observations were made. a) The smoke barrier wall by the ER had unsealed penetration associated with fiber optic wires that were observed above the smoke doors. b.) The smoke barrier wall by patient room #101 had unsealed penetration associated with electrical conduit that was observed above the smoke doors. c.) The smoke barrier wall located by the sleep lab had unsealed penetration associated with computer wires that was observed above the smoke doors. 2. The maintenance person was present when the smoke walls were observed on 04/11/25, and he acknowledged the unsealed penetrations to the smoke wall.”

“CONSTRUCTION CFR(s): The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services. This Standard is not met as evidenced by: 42140 Based on observation, record review and interview, the hospital failed to ensure: 1. integrity of ceiling tiles for one (Mercy Hospital Logan County) of one facilities 2. receptacle for safe disposal of sharps for one (Omnicell room B) of one sharps boxes 3. maintenance of walls in one (Room 108) of two negative pressure patient rooms CEILING TILES On 02/27/25 from 10:16 AM to 11:20 AM, during a tour of the hospital, 12 ceiling tiles were observed to be wet, have brown stains or displaced. Specifically: 1. Room 107 - stained tile at door entrance 2. Swing Bed Activity Room hallway - four stained tiles 3. Room 112 - stained tile at door entrance 4. Hallway at Room 112 - stained tile 5. Hallway at Room 117 - stained tile 6. Rehab Therapy Gym - wet tile 7. ED ambulance entrance - stained tile 8. ED ambulance entrance - two displaced tiles On 02/27/25 at 11:50 AM, Staff AA observed the ceiling tiles and stated when ceiling tiles are wet, stained or displaced, the smoke barrier is compromised. SHARPS BOX On 02/27/25 from 10:16 to 11:20 AM, during a tour of the hospital, a full sharps box was observed in Omnicell room B. Record review showed no sharps box policy. On 02/27/25 at 10:52 AM, Staff J observed the full sharps box and stated it posed the risk of a sharps injury to staff. EXPOSED DRYWALL On 02/27/25 from 10:16 AM to 11:20 AM, during a tour of the hospital, separation of caulk and paint and exposed drywall was observed at the perimeter of the window of patient room 108. Specifically: 1. Both sides of window sill - approximately 6” x ¼” separation 2. Left side of window - approximately 36” x ½” inch separation 3. Right side of window - approximately 6” x ¼” inch separation On 02/27/25 at 10:29 AM, Staff J observed the exposed drywall and stated it posed a risk for infection.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (ii) Policies and procedures for emergency medical services. This Standard is not met as evidenced by: 42140 Based on observation and interview, the hospital failed to ensure unexpired items on crash cart for one (B Crash Cart east hall) of one crash carts. On 02/27/25 from 10:16 AM to 11:20 AM, during a tour of the hospital, expired defibrillator pads were observed on the B Crash Cart in the east hall. Specifically: 1. One package of Regard Adult/Child defibrillator pads that read in part, “LOT # Y040815-01 Use before date: 2018-04-16” On 02/27/25 at 10:59 AM, Staff J observed the expired defibrillator pads and stated they posed the risk of failing to work during a code blue.”

“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: 42140 Based on observation and interview, the hospital failed to ensure terminally cleaned room for one (Room 108) of two negative pressure patient rooms. On 02/27/25 from 10:16 AM to 11:20 AM, during a tour of the hospital, separation of caulk and paint and exposed drywall was observed at the perimeter of the window of patient room 108. Specifically: 1. Both sides of window sill - approximately 6” x ¼” separation 2. Left side of window - approximately 36” x ½” inch separation 3. Right side of window - approximately 6” x ¼” inch separation On 02/27/25 at 10:29 AM, Staff J observed the exposed drywall and stated it posed a risk for infection.”

“SNF SERVICES CFR(s): The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: §485.645(d)(1) Resident Rights (§483.10(b)(7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2) and (4), (f)(4)(ii) and (iii), (g)(8) and (17), (g)(18) introductory text, (h) of this chapter). “ §483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident’s behalf. The court-appointed resident representative exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. “ §483.10(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. “ §483.10(c)(2)(iii) The right to be informed, in advance, of changes to the plan of care. “ §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. “ §483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician. (1) The physician must be licensed to practice, and (2) If the physician chosen by the resident refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in paragraphs (d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment. (3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. (4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the resident’s preferences, if any, among options. (5) If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility must honor that choice. “ §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. “ §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. “ §483.10(f)(4)(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident’s right to deny or withdraw consent at any time; “ §483.10(f)(4)(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent at any time; “ §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident’s own expense. “ §483.10(g)(17) The facility must- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. “ §483.10(g)(18)[introductory text only] The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. “ §483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. (3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident’s medical, social, and administrative records in accordance with State law. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure residents were informed of their rights for 16 (Patients #1, 2, 5, and 13-25) of 16 swing bed patients. Review of the hospital admission packet showed no resident rights for swing bed patients. On 02/27/25 at 3:34 PM, Staff J stated acute care inpatients and swing bed patients receive the same hospital admission packet. On 03/03/25 at 9:06 AM, Staff R stated their ministry (corporate) level was drafting a swing bed patient rights document that will now be given to swing bed patients.”