Newman Memorial Hospital

“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 1 of 7 smoke barrier walls to resist the passage of smoke. Findings: 1. A tour of the facility was conducted on 08/12/25, the following observations were made. 3rd floor smoke wall a) On the north side of the smoke wall one unsealed penetration associated with gray wires was observed above the smoke doors in the attic. b) On the south side of the smoke wall a hole was observed above the smoke doors in the attic. 2. The Plant Manager was present when the smoke walls were observed at 11:05 a.m. on 08/12/25, and stated he was not aware of the holes in the smoke barrier walls.”

“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. Facility maintenance records were reviewed on 08/12/25 at 1:40 p.m., and no documentation was found to show the facility had conducted routine corridor door inspections. 2. The Plant Manager was interviewed during the record review and stated they had never performed corridor door inspections.”

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 41506 Based on observation, record review and interview, the hospital failed to ensure 2 of 2 patients (Patient #21 and #22) being processed for admit were provided with information regarding the hospital’s policy on advance directives and information on the state’s advance directives to assure each patient could effectively exercise their right to make informed decisions about their care. Findings: On 05/28/25 from 11:00 a.m. to 11:30 a.m. observations of two patients (Patients #21 and #22) being admitted to the hospital by the admitting personnel showed no documented evidence of advance directives information being provided to the patients. A review of the hospital policy titled “Advance Directives,” dated 12/2018, read in part, “The purpose of this policy is the provide the requirements for placing advance directives forms into the medical record.” A further review of the policy showed no documented evidence of when or how advance directives information would be provided to the patients. On 05/30/25 at 10:00 a.m. Staff H stated advance directive information was not provided to patients upon admit and patients were only asked if they had an advance directive.”

“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 hospital failed to ensure the nursing staff developed a nursing care plan for each patient based on assessing all the patient’s nursing care needs and not solely those needs related to the admitting diagnosis in 3 of 3 (Patient #1, #2, and #3) medical records reviewed for nursing care plans out of 20 medical records. Findings: A review of Patient #1 medical record, read in part, Patient #1 was admitted to the hospital with a diagnosis of acute kidney injury. A review of the patient’s medical history showed the patient also had a present history of bipolar disorder and chronic obstructive pulmonary disease. The care plan showed the patient only had a documented care plan with goals and treatment plans for weakness, infection, fall risk, pain, and skin integrity. A further review of the nursing care plan and the medical record showed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses of bipolar disorder and chronic obstructive pulmonary disease. A review of Patient #2 medical record, read in part, Patient #2 was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and hypoxia. A review of the patient’s medical history showed the patient also had a present history of diabetes and hypertension. The care plan showed the patient only had a documented care plan with goals and treatment plans for chronic obstructive pulmonary disease, pain, and skin integrity. A further review of the nursing care plan and the medical record showed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses of diabetes and hypertension. A review of Patient #3 medical record, read in part, Patient #3 was admitted to the hospital with a diagnosis of postoperative care. A review of the patient’s medical history showed the patient also had a present history of hypertension, constipation, and anemia. The care plan showed the patient only had a documented care plan with goals and treatment plans for skin integrity, infection, pain, and falls. A further review of the nursing care plan and the medical record showed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses of hypertension, constipation, and anemia. A review of the hospital policy titled “Care Planning,” dated 03/2021, read in part, “Care, treatment, and services are planned to ensure that they are individualized to the patient’s needs. The hospital shall provide an individualized plan of care for all patients that is appropriate to the patient’s needs, strengths, limitations, and goals.” On 05/29/25 at 11:55 a.m. Staff D stated the nurses only developed patient care plans based on the patient’s main diagnoses and stated the care plans were not comprehensive or developed for all the patient’s current diagnoses or care needs.”

“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 maintained a functional and sanitary environment, according to acceptable professional standards of infection control practice as evidenced by: 1. failing to ensure surgical staff processed surgical items according to acceptable sterilization guidelines and/or manufacturer’s IFU when processing and sterilizing surgical items in paper-plastic peel pouches in observations of 15 of 15 paper-plastic peel pouches that were not light weight or low profile and were double-pouched, 2. failing to ensure dietetic staff maintained safe food storage practices by observations of nutritional items being stored in 12 of 12 cardboard boxes in the refrigerator, and 3. failing to ensure staff labeled the HLD test strip bottle when opened with the open date and the new expiration date in 1 of 2 observations of HLD test strip bottles. Findings: 1. failing to ensure surgical staff processed surgical items according to acceptable sterilization guidelines and/or manufacturer’s IFU when processing and sterilizing surgical items in paper-plastic peel pouches in observations of 15 of 15 paper-plastic peel pouches that were not light weight or low profile and were double-pouched, On 05/28/25 at 12:10 p.m., observations in the Sterile Supply Room showed sterile items processed in paper-plastic peel pouches that were not low profile with visible tenting and creasing of the sterile packages. Further observations showed sterile items processed in paper-plastic peel pouches that were not light weight with visible stress on the package’s sealed seams. The sterile paper-plastic peel pouches were also observed to be double-pouched with the inner pouch sealed. A review of the AORN Guidelines for Perioperative Practice 2021 edition: Guidelines for Packaging Systems, read in part, Use peel pouches (i.e., paper-plastic, polyethylene material, polyester film) according to a manufacturer IFU and/or according to AORN packaging guidelines. Sterile items processed in peel pouches should be light weight and low profile to maintain the sterility of the package contents and not compromise the package or the seal integrity (caused by heavy items or tenting). Sterile peel pouches should not be double-pouched (placing the item in one pouch and then placing this pouch inside another) with the inner pouch sealed unless the pouch manufacturer’s IFU allows this practice. Improper double pouching may entrap air and/or inhibit sterilant contact and can lead to polyethylene material seal failure. Sterility is event-related and not time-related and may be affected by events such as, amount of handling, improper storage, and properties of the packing material. A review of the hospital policy titled “Event-Related Sterility Maintenance,” dated 04/29/2025, read in part, “Events that may compromise the sterility of packages include ...packaging materials. All items processed for sterilization will be properly wrapped and processed.” On 05/28/25 at 12:10 p.m. Staff E stated that all sterile items processed in paper-plastic peel pouches were double-pouched with the inner pouch sealed. Staff E stated they were aware that sterile items processed in paper-plastic peel pouches were supposed to be light weight and low profile and they were not aware there were so many sterile items packaged incorrectly. They stated their policy did not address specific paper-plastic peel pouch guideline requirements. Staff E further stated the manufacturer of the paper-plastic peel pouches approved double-pouching but did not know if the manufacturer approved sealing the inner pouch. 2. failing to ensure dietetic staff maintained safe food storage practices by observations of nutritional items being stored in 12 of 12 cardboard boxes in the refrigerator. On 05/28/25 at 4:30 p.m. observations in the dietary department’s refrigerator showed nutritional food items being stored in their original cardboard boxes. The cardboard boxes were observed to be stacked on top of one another in the refrigerator and were noted to be damp when touched. A review of the hospital policy titled “Food Storage,” dated 08/2017, read in part, “Food items will be stored, thawed, and prepared in accordance with good sanitary practice.” The CDC guidelines on Food Safety in Healthcare, read in part, The USDA and the CDC advise against storing cardboard boxes in refrigerators. While cardboard boxes can be a convenient storage solution, it’s not recommended for food safety due to the potential for moisture, bacteria, and increasing the risk of contamination. Moisture can damage the cardboard, potentially affecting the contents or creating a breeding ground for bacteria. Cardboard may not be as effective at maintaining consistent temperatures of food items, causing temperature fluctuations which can potentially affect the stored items. On 05/28/25 at 4:40 p.m. Staff G stated the dietary personnel kept nutritional foods items in their original cardboard boxes and stacked the boxes on top of one another, due to space limitations and refrigerator storage convenience. Staff G stated they were not aware of the food safety guidelines on cardboard box use in refrigerators. 3. failing to ensure staff labeled the HLD test strip bottle when opened with the open date and the new expiration date in 1 of 2 observations of HLD test strip bottles. An observation on 05/28/25 at 12:20 p.m. of two HLD test strip bottles showed one of the HLD test strips bottles was not labeled with the open date or the new expiration date. A review of AORN Guidelines for Perioperative Practice, 2021 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 180 days after opening the bottle. The strips should be used within 180 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, so it’s important to discard them when expired.” On 05/28/25 at 12:20 p.m. Staff E stated the open date and the new expiration date for one HLD test strip bottle was not labeled on the bottle. On 05/30/25 at 11:30 a.m. the infection control breaches were discussed with Staff F. Staff F stated they were not aware of the above infection control issues, as the above processes were not routinely being monitored in infection control. Staff F stated the facility followed AORN, APIC, and CDC in their infection control program.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to provide a medical screening that included assigning an Emergency Severity Index, the use of VS, lab work, and diagnostic testing (per their policy) on 01/17/25 for one (Patient #8) of 20 patients. This failed practice had the likelihood for an emergency medical condition to go unrecognized, cause a delay in treatment and a risk to patient safety and possible adverse health outcomes. (see 2406)”

“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: 39648 Based on record review and interview, the hospital failed to provide a medical screening that included assigning an Emergency Severity Index, the use of VS, lab work, and diagnostic testing (per their policy) on 01/17/25 for one (Patient #8) of 20 patients. This failed practice had the likelihood for an emergency medical condition to go unrecognized, cause a delay in treatment and a risk to patient safety and possible adverse health outcomes. Findings: Review of policy titled “Triage” number: NSG.6230.828 with a review date of 06/30/23 read in part: 1. The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either resuscitative, emergency, urgent, semi-urgent or routine categories; 2. Resuscitative (level 1) - immediate care, life-threatening conditions; 3. Emergency (level 2) - major injury or illness but stable; treatment and reassessment should occur within five to 15 minutes; 4. Urgent (level 3) - treatment and reassessment should occur in 15-45 minutes; 5. Semi-Urgent (Level 4) - treatment and reassessment should occur in one to two hours.” Review of policy titled “Assessment and Reassessment Emergency Department” with a review date of 06/30/24 read in part, “The Emergency Department nurses shall initiate accurate and ongoing assessment of physical and psychosocial needs of patients within the emergency department...All patients admitted to the Emergency Department will have the following documentation:... Initial vital signs, Additional vital signs shall be obtrained depending on the patient’s condition. Critical patients every five to fifteen minutes, as needed. Intermediate every one hour. All other partients every two hours or prior to discharge.” Patient #8 A review of the medical record showed: 1) A form titled, “The History of Present Illness” documented prior to emergency medical personnel transporting the patient to the hospital the patient’s primary physician prescribed Hydrocodone 10-325 mg 1 tablet by mouth every 6 hours as needed for pain and Fentanyl 12 mcg patch for pain (first patch placed transdermally 1/16/25 on day prior to arrival); 2) A Darrouzett EMS Short Form documented the patient vomited and complained of pain while enroute to the hospital 01/17/25: a) An IV was placed 01/17/25 at 12:26 am; b) Morphine 2 mg IV 01/17/25 was administered at 12:18 am; c) Zofran 4 mg IV 01/17/25; d) Morphine 2 mg IV 01/17/25 at 12:28 am; e) Morphine 2 mg IV 01/17/25 at 12:28 am; f) Morphine 2 mg IV 01/17/25 at 12:30 am; g) Morphine 2 mg IV 01/17/25 at 12:30 am was administered for a total of Morphine 10 mg IV; 3) 01/17/25 at 1:04 am patient arrived at the Emergency Department via EMS, complaining of back pain and pain in both legs (the patient had a reported history of suspected metastatic cancer with a pathological lumbar spine fracture); 4) Admission vital signs (VS): a) blood pressure of 130/114, pulse 60, temperature 98.0, and oxygen saturation 95% on oxygen (no date and time documented). b)No VS located in the medical record (provided to the surveyor) and no re-check documented; 5) No lab work was ordered to determine current physiological status (hydration, malnutrition, etc..); 6) No diagnostic testing was completed to rule out illnesses, other fractures, spinal cord injury, or bowel impaction/obstruction. (an MRI dated 01/10/25 showed “.... appearance is concerning for a metastatic process affecting L1, L4 and L5 and this appears to have led to a pathologic compression fracture to L4 vertebrae);” 7) ED documentation dated 01/17/25 showed no Emergency Severity Index assigned in triage; 8) ED documentation dated 01/17/25 showed no nursing assessment completed. 9) Patient left the emergency department via EMS 01/17/25 at 4:14 am enroute to home. The discharge diagnoses were: a) bilateral sciatica; b) chronic low back pain with bilateral sciatic, unspecified back pain laterally; c) chronic prescripation opiate use. The HPI shows the patient’s primary physician had been evaluating patient for malignancy. The patient’s primary physician started the patient on narcotics for pain management and the patient was to be set up for an appointment with an oncologist for a PET scan. Pain symptoms increased and the paient received a prescription for fentanyl patches. On 03/13/24 at 3:30 pm, Staff A stated, 1. The triage level was not assigned to Patient #8; 2. There was nothing documenting the BP was re-checked; 3. The nursing assessment was not completed. On 03/20/25 at 11:59 am, Staff J stated “I didn’t feel it was necessary to order testing with the presenting symptoms and the history I had read.””

“GRIEVANCES CFR(s): § 485.614(a)(2) Grievances The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure notice of patient rights for five (Patients # 8, 11, 17, and 19) of 5 patients who requested a printed copy of patient rights. Findings: A Review of a facility document titled, “Partient Bill of Rights Handout” showed an address for the SSA that was vacated in November 2020. On 03/14/25 at 10:20 am Staff A was shown the correct address and phone number for the SSA. On 03/14/25 at 10:20 am Staff A stated the contact information for the Oklahoma State Department of Health provided by the facility was not correct.”