Drumright Regional Hospital

“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 interview, the facility failed to maintain and test quarterly, a complete automatic sprinkler system. On 05/15/26 at 12:10 p.m., the quarterly sprinkler documentation for 2026 was reviewed. The facility could not provide any documentation the quarterly sprinkler inspections for the first quarter of 2026 and the fourth quarter of 2025 were completed. 2. On 11/25/25 at 12:20 p.m., the CEO and maintenance supervisor acknowledged the first quarterly sprinkler of 2026 and the fourth quarter of 2025 inspections had not been performed.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 12713 Based on record review and interview, the facility failed to properly maintain an emergency stop kill switch, remotely located for the generator. On 05/15/26 at 11:20 a.m., a tour of the facilities generator was conducted. The generator was not equipped with an emergency stop kill switch. In the event of a generator fire/emergency, the facility could not be assured the generator could be powered down remotely. On 05/15/26 at 11:30 a.m., the maintenance supervisor was interviewed and acknowledged the generator was not equipped with the required emergency stop kill switch.”

“AGREEMENTS FOR CREDENTIALING AND QLTY ASSURAN CFR(s): Each CAH that is a member of a rural health network shall have an agreement with respect to credentialing and quality assurance with at least-- (1) One hospital that is a member of the network; (2) One QIO or equivalent entity; or (3) One other appropriate and qualified entity identified in the State rural health care plan. This Standard is not met as evidenced by: 41506 Based on record review and interview, the facility failed to ensure that each physician or practitioner’s credentialing file contained a request for specific clinical delineation of privileges when they applied for reappointment, according to the facility’s Medical Staff By Laws, in six (Staff I, J, K, L, M, N) of six credentialing files reviewed. Findings: A review of Staff I, J, K, L, M, N physician/practitioner credentialing files showed no documented evidence of the physician/practitioner’s request for specific clinical delineation of privileges when applying for reappointment since 2020. A review of the facility’s Medical Staff By Laws, approved in 2025, read in part, “All appointments and reappointments to the Medical Staff shall be for a period of two (2) years ...every application for appointment and reappointment to the Medical Staff must contain a request for the specific Clinical (delineation) Privileges desired by the applicant.” On 03/09/26 at 1:00 p.m. Staff B stated the facility had a contract agency responsible for credentialing all physician/practitioners to the medical staff since 2020. They stated the contract agency was not required to obtain specific clinical delineation of privileges from the physician/practitioners when they apply for reappointment. Staff B stated this task was the responsibility of the facility. They stated the facility had not decided who in the facility would be responsible for this task and clinical delineation of privileges had not been requested from the physician/practitioners upon reappointment.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 41506 Based on observation, record review, and interview, the facility failed to ensure a multi-dose vial when opened in a patient care area became single use and discarded after use and an opened single dose vial was discarded after use and not available for other patients in one (OR#2) of two operating room anesthesia carts. Findings: On 03/06/26 at 12:00 p.m. an observation showed in OR#2’s anesthesia cart, an opened multi-dose vial of 2% Lidocaine 20 ml and an opened Bridion 2 ml single dose vial available in the cart for other patient use. A review of the CDC Guide to Infection Prevention, September 2016, read in part, “Dedicate multi-dose vials to a single patient whenever possible. If multi-dose vials are used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle). Multi-dose vials opened in a patient care area will be considered single dose and discarded after use ... single dose medication vials should be single patient use only.” On 03/06/26 at 12:00 p.m. Staff E stated they were not aware that multi-dose vials when opened in a patient care area must be dedicated to single patient use and discarded after use. They stated single use medications are single dose and the Bridion should have been discarded after use. Staff E stated the facility policy on multi-dose vials did not address multi-dose vials when opened in patient care areas.”

“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 facility failed to ensure the nursing staff developed a nursing care plan for each patient based on assessing all the patient’s care needs and not solely those needs related to the admitting diagnosis for two (Patient #1, #6) of two patients out of 20 patient medical records reviewed for nursing care plans. Findings: A review of Patient #1 medical record read in part, Patient #1 was admitted to the hospital as an inpatient on 03/03/26 with a diagnosis of pain from a fall. The patient’s medical history showed the patient had a history of dehydration, hypertension, colitis, and diabetes. The current care plan showed the patient only had a documented care plan with goals and treatment plans for falls and pain. The medical record showed no documented evidence that the patient had a care plan developed for dehydration, hypertension, colitis, or diabetes. A review of Patient #6 medical record read in part, Patient #6 was admitted to the hospital as an inpatient on 02/23/26 with a diagnosis of infection. The patient’s medical history showed the patient had a history of congested heart failure and diabetes. The current care plan showed the patient only had a documented care plan with goals and treatment plans for congested heart failure, skin integrity, and falls. The medical record showed no documented evidence that the patient had a care plan developed for diabetes. On 03/09/26 at 3:30 p.m. Staff C stated the nurses developed patient care plans based on the admitting diagnoses and patient care plans were not based on assessing all the patient’s care needs and current diagnoses.”

“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 facility failed to ensure staff: a. processed surgical items in paper-plastic peel pouches according to acceptable sterilization guidelines for peel pouch use in observation of six of six sterilized peel pouches in the sterile supply room that were not low profile, light weight, and were doubled pouched, b. labeled 20 of 20 processed sterile packages in the sterile supply room with the autoclave number and the load number, and c. labeled two of two HLD test strip bottles in the decontamination areas with the new expiration date after opening. Findings: PEEL POUCHES On 03/09/26 at 10:15 a.m. observations in the sterile supply room showed at least 6 sterile items processed in paper-plastic peel pouches that were not low profile with visible tenting and creasing of the sterile packages, not light weight with visible stress noted on the package’s sealed seams, and doubled peel pouched. A review of the AORN Guidelines for Perioperative Practice 2025 edition: Guidelines for Packaging Systems, read in part, “Peel pouches (i.e., paper-plastic, polyethylene material, polyester film) should be used for small, lightweight, and low-profile items to maintain the sterility of the package contents and not compromise the package or the seal integrity caused by heavy items or tenting. All seals should be completely closed and smooth, without gaps, folds, bubbles, or wrinkles. The integrity of the seal and sterility of the pouch could be compromised by uneven sealing or channels created by wrinkles or folds in the packaging material ...Do not use double pouching unless the pouch manufacturer’s IFU allows this practice ...Sterility is event-related and may be affected by particular events such as ...improper packaging.” On 03/09/26 at 10:20 a.m. Staff E and G stated they knew that items processed in paper-plastic peel pouches were supposed to be lightweight, but they were unaware of the low-profile and double pouching guidelines. Staff E stated the facility did not have a policy specific to peel pack guidelines or a written IFU from the manufacturer on the use of double peel pouching. PACKAGE LABELING On 03/09/26 at 11:00 a.m. observations in the sterile supply room showed at least 20 processed sterile packages that were not labeled with the autoclave number or the load number. A review of the AORN Guidelines for Perioperative Practice 2025 edition: Guidelines for Packaging Systems, read in part, “Label packages to be sterilized with required information. Package labels should be visible and legible, be written on the plastic side of the pouches, identify the autoclave, cycle, and load number, description of the contents, identity of personnel who prepared and wrapped the package, and remain securely affixed through handling, storage, and transport, and to the point of use ...This information is important and allows items to be identified in the event of sterilization processing error or equipment malfunction.” On 03/09/26 at 11:00 a.m. Staff G stated they were not aware the sterile packages also had to include the autoclave number and the load number. TEST STRIP BOTTLES On 03/09/26 at 11:20 a.m. an observation of 2 HLD test strip bottles in the decontamination areas showed the 2 HLD test strip bottles were not labeled with the new expiration date when opened. A review of AORN Guidelines for Perioperative Practice, 2025 edition: Guideline for High-Level Disinfectant, read in part, “Use a test strip specific to the disinfectant before each use of the HLD solution to determine whether the concentration of the active ingredient in the HLD is above or below the minimum effective concentration. Use and store the test strips in accordance with the manufacturer’s IFU.” A review of the test strip manufacturer IFU, read in part, “The test strips have a shelf life of 120 days (4 months) after opening the bottle. The strips should be used within 120 days of opening or before the printed expiration date on the bottle, whichever comes first. Date the bottle with the open date and the new expiration date after opening. Expired test strips can provide inaccurate results and must be discarded upon expiration.” On 03/09/26 at 11:30 a.m. Staff G and H stated the 2 HLD test strip bottles were not labeled with the new expiration dates after opening. On 03/09/26 at 11:40 a.m. Staff E stated they were not aware of the above AORN surgical guidelines. They stated the facility followed the AORN Perioperative Nursing Scope and Standards of Practice and the AORN Guidelines.”