Cleveland Area Hospital

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 12713 Based on observation and staff interview, the facility failed to install smoke detectors in activity room that were open to the corridor. Findings: 1. A tour of the facility was conducted on 07/10/2024, and the following observations were made: a. The activity room next to patient room 209 and the room next to the mock apartment did not have a door and was open to the corridor. These two rooms were not equipped with required hard wired smoke detectors to protect the rooms since the two doors have been removed. 2. The Manager of Maintenance/Environmental Services was present during the tour of the facility and acknowledged the observations.”

“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. Findings: 1. The facility records were reviewed on 07/10/2024 at 1:45 p.m. The most recent annual sprinkler inspection document was dated 05/15/2024. A quarterly sprinkler inspection should have been performed in the first quarter of 2024 and the fourth quarter of 2023, but no documentation was found for the two missing quarterly sprinkler inspections. 2. The Manager of Maintenance/Environmental Services was present during the record review on 07/10/24 and stated the inspection company failed to perform the quarterly inspections for the past year.”

“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 non-rated corridor doors and pateint room doors throughout the hospital. Findings: 1. The facility records were reviewed on 07/10/2024 at 1:30 p.m., and no documentation was found to show the facility had conducted routine corridor door inspections. 2. The Manager of Maintenance/Environmental Services were interviewed during the record review and she stated they do rountine repairs and inspections, but they did not document the inspections. Maintenance, Inspection & Testing - Doors 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)”

“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 was maintained. This was evidenced by: 1) the failure to identify the Registered Dietician that was providing oversight of the dietary department, 2) the failure of the list to identify the nature and scope of the contract service, and if the service was being provided on-site or off-site. Findings: 1) An interview with Staff B on 03/12/24 at 1:50 p.m. revealed Staff O was identified as the contract dietician. Review of the list of contract services revealed a contract identified as Nutrition Management Services which was requested and provided on 03/14/24. Review of the contract revealed Staff O was not identified. During review of the employee records the Human Resouce Director was asked if there was any information related to Staff O and she replied “no”. Staff B then produced a license for Staff O on her phone for review; 2) Review of the list of contract services revealed only the name of the contract and not the nature or scope of the service provided and if the contract was provided on-site or off-site.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 41505 Based upon observations, record reviews and interviews, the hospital failed to ensure the Registered Nurses who provided patient care in the Emergency Department were competent in mixing and administering critical medications in the emergency setting. Findings: Observations in the Emergency Department (ED) and interview with Staff B during the initial hospital tour on 03/12/24 at 11:05 a.m. revealed when asked what medications were pre-mixed, she replied the Registered Nurse was responsible for mixing and administering all critical medications used in the ED. A book was provided for review which identified 26 medications along with the solution, dosing instructions, how to titrate the medication, and patient monitoring. According to Staff B, during the initial orientation and annually thereafter, the Registered Nurse would do a return demonstration for mixing and dosing the critical medicines. Review of the evaluation forms for the Registered Nurse revealed Medication Administration was identified, however; mixing and administration of the critical medications was not, nor was there evidence a return demonstration was conducted to ensure competency.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 41505 Based upon observation, record review and interview, the hospital failed to ensure surveillance of the nursing staff was conducted to ensure the Registered Nurse properly reconstituted powdered vials of antibiotics in accordance with recognized guidelines. Findings: Observations on 03/14/24 at at 2:00 p.m. revealed Staff G was in the medication room preparing an Intravenous (IV) Antibiotic for infusion. There were two vials of Ceftriaxone 1 gram in the powder form, two 10cc (cubic centimeter) syringes with needles attached and a 100 cc bag of 0.9% Normal Saline on the counter. Staff G removed a three sided white plastic tray from behind the sink, place it on the counter next to the sink, and put the IV bag of saline, the syringes, an alcohol prep, and the vials of Ceftriaxone on the tray. Staff G then withdrew 10cc’s from the rubber port on the IV bag, inject the saline into the first vial of the Ceftriaxone, mix the two together and withdraw the mixture with the 10 cc syringe. The medication was then injected into the rubber port of the saline bag (second entry). During the first reconstitution, a fly had landed on the tray and was walking around. Staff G had picked up the second 10cc syringe and was preparing to enter the rubber port of the IV saline bag but was stopped by the surveyor who advised her of the fly on the tray. Since there were no disinfection wipes in the medication room, Staff B, who was in attendance during this observation, retrieved a container of wipes. Once the lid was opened, Staff G noticed there were no wipes visible in the perforated opening so she attempted to stick her hand into the opening but was unable to reach the wipes. The lid was removed, a wipe obtained, and the fly was removed with a wipe and thrown into the trash can. The IV supplies were moved to the left side of the tray and Staff G cleaned only three quarters of the right side. When Staff G was going to resume reconstituting the antibiotic medication she was stopped by the surveyor who instructed her hand hygiene needed to be performed. Staff G washed her hands and retrieved the second 10cc syringe and re-enter the IV saline bag, withdraw 10cc’s of saline (3rd entry) then reconstitute the second vial of Ceftriaxone. The 10cc syringe was used to enter the rubber port of the bag of IV saline (4th entry) and the antibiotic was added. This same 100cc of 0.9 Normal Saline solution was then administered to the patient. Interview with Staff B on 03/14/24 at 3:15 p.m. revealed during the initial orientation and the annual evaluation each Registered Nurse had to complete a return demonstration of reconstituting Intravenous medications to ensure proper technique was maintained. Review of the pre-printed evaluation forms revealed medication administration was identified but there failed to be documented evidence the Registered Nurse did a return demonstration to ensure competency. Review of the Oklahoma Pharmacy Law Book, 2023, Laws and Rules Pertaining to the Practice of Pharmacy, Oklahoma Statutes, Title 59, Chapter 8, and Oklahoma Administration Code (OAC) Title 535 page 121, (1) Low Risk Level CSP’s (Compounded Sterile Preparations); B) The compounding involves only transfer, measuring, and mixing manipulations using not more than three commercially manufactured packages of sterile products and not more than two entries into any one sterile container or package (e.g., bag, vial) of sterile product or administration container/device to prepare the CSP. C) Manipulations are limited to aseptically opening ampoules, penetrating disinfected stoppers on vials with sterile needles and syringes. and transferring sterile liquids in sterile syringes to sterile administration devices and package containers of other products, and containers for storage and dispensing.”

“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 a written transfer agreement was implemented for 1 of 3 Emergency Department Patients who required further in-patient psychiatric care (#9). 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 record (or copies) related to the patient’s emergency medical condition were provided to the receiving hospital. Findings: 1) Review of the Emergency Department (ED) Log revealed on 01/11/24, patient #9, a 13 year old male, had Suicidal Ideations and presented to the ED for a “Medical Clearance”. Review of the ED record revealed a therapist from Hospital Q instructed the patient’s mother to take the patient to the ED to be medically cleared for In-Patient Psychiatric Care. According to the “History of Present Illness” completed by the ED Physician, the following was revealed “...Family did contact (Hospital Q) who is currently looking for placement for the patient and have requested he come here for medical clearance...” Review of the “Medical Decision Making” revealed “Patient taken to exam room, history gathered and physical exam performed as noted above. Patient calm and cooperative in the examination room. Does admit to suicidal ideation and did reportedly hold a knife to his throat approximately 5 days ago. Denies homicidal ideation, auditory hallucinations. Laboratory studies were performed for medical clearance.” “(Hospital Q) was contacted. Patient has been given an inpatient bed for further evaluation. Patient will be discharged from the emergency department and his mother will take him directly to the facility. She does appear reasonable and this is an appropriate option. Patient discharged in stable condition.” The hospital patient #9 was transferred to was not identified. Further review of patient #9’s ED record revealed the hospital failed to implement a written transfer agreement when the patient required further inpatient treatment at a psychiatric hospital. Interview on 03/13/24 at 3:15 p.m. with Staff D revealed when Hospital Q determined a psychiatric patient required inpatient care, they would send the patient to their ED for medical clearance. During this interview Staff B was present and added once the medical clearance was completed Hospital Q was responsible for forwarding the information to the accepting psychiatric hospital. When asked why a transfer agreement was not implemented on patient #9, Staff B replied their ED was only used for medical clearance to ensure the patient was medically stable for inpatient psychiatric treatment.”