Jefferson Hospital

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 42809 Based on review of facility documents and employee interviews (EMP), it was determined the facility failed to ensure the condition of the physical plant was maintained in such a manner that the safety and well-being of patients are assured (A0701), and subsequently experienced a fire on the penthouse roof top on September 3, 2024. In addition, the facility failed to maintain written evidence of regular inspection and approval by State or local fire control agencies (A0175). Cross reference: 482.41(a) Physical Environment: Buildings. 482.41(b)(6) Physical Environment: Life Safety From Fire”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 45574 Based on a review of facility documents, tour, and employee interview (EMP), it was determined the facility failed to comply with policy while welding on the facility’s roof top which resulted in a spark causing a fire on September 3, 2024. Findings include: On September 4, 2024, a review of facility policy, “Hot Works Permits” (Last Revised: 10/1/2019; Last Approved 1/6/2023) revealed, “Terms and Definitions: A. Hot Works Projects- An activity that may result in sparks, fire, molten slag or hot material that has combustible potential that could cause fires or explosions. 1. Hot Works Project Examples include: welding, soldering, cutting thawing pipes, brazing, grinding, torch applied roofing, etc ... D. OSHA requires fire prevention activities when welding or doing hot works including: 1. If possible and practical, relocate combustibles at least 35 feet from the work site. If relocation of combustibles is not practical, protect/shield combustibles with flame proof covers, metal guards to prevent ignition. 2. Shut down or protect HVAC systems, ducts or other sources that may carry sparks to far away combustibles. 3. Fire resistant shields will be used to prevent ignition when welding or cutting is performed near walls, partitions, ceilings or roof combustible construction materials. 4. To prevent ignition of combustibles on the other side of a metal wall, partition, roof or ceiling, precautions will be taken by placing a fire watch, person who will be posted on the opposite side of the wall to watch for sparks and ignition... .” A review of facility documents revealed that on September 3, 2024, at 11:19 AM, a spark from welding on the hospital “penthouse roof” contacted roof insulation resulting in fire and smoke and initiation of the facility’s fire response plan. Smoke entered the facility through the roof air handler. There was response from multiple fire departments. On September 4, 2024, between approximately 1:00 PM and 1:20 PM, a tour of the roof and penthouse were conducted. Visual inspection of the affected area on penthouse roof, revealed an area of roofing material measuring approximately ten feet by fifteen feet was removed, exposing the steel roof decking material beneath. The roofing material cut away was approximately ten inches thick, and consisted of a rubberized top layer, with multiple layers of foam insulation boards laying atop a corrugated steel decking surface. EMP3 was present and demonstrated the locations of the welding work and fire that occurred on September 3, 2024. Palpable air flow was noted to be drawn into the penthouse from a gap in the roof decking near where the fire had occurred. EMP3 confirmed that this gap was present on the day of the incident as well as a large opening, approximately two foot by four foot, created for the future air handler. During an interview on September 4, 2024, at 9:49 AM, EMP3 stated that the roof fire was contained by use of facility fire extinguishers, both ABC and “dry chem.” The fire department hosed a smoldering area with water. All fire units were released on September 3, 2024, at approximately 2:00 PM. During an interview on September 4, 2024, at 11:06 AM, EMP8 stated that the roof project was a part of the bigger project which was the replacement of the rooftop HVAC system. The construction team was working to add additional support to the “penthouse” roof to accept the “weight of the new HVAC system.” EMP8 and EMP 9 explained the job was bid to “patch in” the supports for the new HVAC system and that the job needed to be watertight by the end of each work day. During an interview on September 5, 2024, at 10:01 AM, EMP10 detailed that this project was “novel” and could not be approached in a “conventional process” since there was penetration of the roof assembly and drawing outside air into the work area. EMP10 also stated that it was not “possible or practical” to relocate combustibles (insulation) or to shut down the HVAC system and have “stale air” in patient areas. During an interview on September 6, 2024, at 9:30 AM, EMP11 explained being responsible for conducting the roof weld for the “duct stand.” EMP11 described that the right weld was completed and as EMP11 began the left weld, “My fire watch stated that he saw smoke.” EMP11 stated that they were not using fire blankets. EMP11 stated the fire blankets were “below” (in the penthouse) in EMP11’s “gang box” (toolbox). EMP11 stated that the work area was approximately 16 inches by 12 inches and had “some concern” with the size of the work area. However, the welding team was “blowing and cleaning the decking before the welding work” to reduce hazards. During an interview on September 6, 2024, at approximately 9:40 AM, EMP10, further explained that it had been decided to keep the work area “as small as possible” to prevent water infiltration and assure the work area would be “watertight” at the end of each workday. In addition, EMP10 acknowledged that fire blankets are “heavy duty,” and in a work area of this size, the fire blanket would eliminate the contractors “room to work” and could not be used. During an interview on September 6, 2024, at 9:30 AM, EMP11 confirmed that the facility did not use “flame proof covers...” (fire blankets) when completing the welds, on September 3, 2024, for the roof “duct stands.”

“REGULAR FIRE AND SAFETY INSPECTIONS CFR(s): 482.41(b)(8) (6) The hospital must maintain written evidence of regular inspection and approval by State or local fire control agencies. This Standard is not met as evidenced by: 50899 Based upon a review of facility documents and employee interview (EMP), it was determined that the facility failed to maintain written evidence of regular inspection by local fire control agencies. Findings include: On September 4, 2024, at approximately 9:15 AM, a request was made for documentation of fire inspection by the local fire control agency. At approximately 2:15 PM, two letters from the local Fire Chief were provided by EMP3. One undated letter was a commitment of resources by the fire department incase of emergency to evacuate wheelchair bound patients from the dialysis suite on the second floor of the medical office building. The second undated letter was an acknowledgement of a meeting in May, 2024, between EMP3 and the Fire Chief about a kitchen sink being placed near a fire suppression system in the kitchen. The Fire Chief had requested a paper towel dispenser be moved away from the suppression system activation handles. Neither document provided evidence that the facility conducted regular inspections by stat or local fire agencies. On September 4, 2024, at 2:30pm, EMP3 confirmed there was no documentation or evidence of regular inspections and approval by State and local fire department.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42809 Based on review of facility documents, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure telemetry alarms were working correctly for one of five telemetry medical records reviewed (MR1). Findings include: Review on June 5, 2024, at approximatley 2:00 PM, of the facility’s “Patient Rights and Responsibilities POL-6602082” dated July 6, 2023, revealed, “... AHN is committed to honoring patient’s rights ... Care Deliver: You have the right to: ... Receive kind, respectful, safe, quality care delivered by skilled staff. ... Receive efficient and quality care with high professional standards that are continually maintained and reviewed. ...”. Review on June 5, 2024, at 1:45 PM, of the facility’s “RN Registered Nurse” job description revealed, “The Registered Nurse assesses human responses and plans, Implements and evaluates nursing care for individuals or families for whom the nurse is responsible. The Registered Nurse is fully responsible for all actions as a licensed nurse and is accountable to patients for the quality of care. ... Essential Responsiblities: Considers maintenance of a safe environment, patient condition, complexity of the intervention and predictability of the outcome. ...”’. Review on May 31, 2024, at approximately 1:00 PM, revealed, “November 14, 2019... GE Healthcare safety notice: Telemetry alarms may not sound ... GE Healthcare ... released six potential safety issues with its Apex Pro Telemetry system under certain conditions. ... is out of wireless range, its battery has been depleted or a communication failure between the server and transmitter has taken place, a ‘no telem’ condition occurs. This condition, along with ‘ECG leads fail,’ system time changes and system restarts, is related to the potential safety issues, according to the safety notice. ... Patients can experience ECG arrhythmias before and after a ‘no telem’ condition and may not re-activate after the condition is resolved. Third could result in delayed treatment for the potentially life-threatening ECG arrhythmia event. ...”. Review on May 31, 2024, of a facility document dated May 9, 2024, revealed, “ ... Telemetry system completely failed. Staff were unaware that [MR1] was not on the monitor as it was not alarming at the of the event. There was no rhythm appearing on the telemetry monitor. New electrodes and batteries had just been placed in the telemetry pack. Telemetry pack was pulled out of use. Biomed came and took pack and said it was a ‘Synthesizer Error.’ Biomed to repair Telepak. ... Only this telemetry box and patient were effected by the outage. The patient had come back onto the monitor after the RN Troubleshot the box, batteries were replaced and new electrodes were placed. Staff did not become aware of the new outage when the patient was found unresponsive on the floor. ... 5/7: Telemetry pack was repaired and brought back into services after synthesizer error was cleared. ...”. Review of MR1 on June 4, 2024, at approximatley 12:00 PM, of an “H&P date of service 5/7/2024 12:26 PM” revealed that the patient was admitted to the Emergency department on May 7, 2024 at 11:42, for increased shortness of breath and found to be hypoxic. The patient was unresponsive on May 8, 2024, and a “Code” was started at 03:44:21, compressions and epinephrine was administered, and the patient’s cardiac rhythm returned to “Sinus tachycardia”. The code ended at 04:09:14. The patient was transferred to the intensive care unit. After the code the family placed the patient on comfort care and MR1 ceased to breath on May 9, 2024, at 14:09. Review on June 4, 2024, at approximatley 2:00 PM, of a nursing note for MR1, dated May 8, 2024, 4:26 AM, revealed, “... RN was doing hourly rounding around 0310. Pt was in bed, bed alarm on, leads and batteries were changed due to heart monitor saying no telemetry, ... Around 0335, ... pt was found unresponsive in the bathroom with oxygen off. .. Pt was taken to bed, CPR was started and code was called. ...”. The above findings were confirmed by EMP1 on May 31, 2024, between 12:00 and 12:30 PM.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42809 Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined the facility failed to document rhythm strips of monitored patient per facility policy for one of three medical records reviewed (MR7), and failed to document telemetry battery changes of telemetry patients two of three medical records reviewed (MR7 and MR9). Findings include: Review on June 5, 2024, at 2:00 PM, revealed a policy, “Bedside Monitoring System Policy #60.3.3.07 POL-5423719”, which indicated, “... 1. General Monitoring information. ... Batteries will be changed every 24 hours. ... Documentation of the rhythm strips will be done every 4 hours in critical care units and every 8 hours in other areas. ... An alarm history review is completed by the nurse at the end of every shift. ... For monitored patients, documentation of cardiac rhythm includes strip, patient name, room number, date, time, lead, heart rate, ... QRS duration QT interval ... Quarterly monitoring will be done by Clinical Engineering Department and results will be reported to the Patient Safety Committee. ...”. Review of MR7 on June 7, 2024, at approximatley 11:00 AM, revealed that the patient was admitted to the hospital on May 25, 2024, at 0100. Further reviewed revealed that he patient was transferred to 5 west from the emergency department at 1218, and required stenting to the left anterior descending artery. Continued review revealed that MR7 was placed on the cardiac monitor on May 24, 2024, at 23:00, and that nursing staff failed to document the QT and QRS waves on May 26, 2024, at 7:00 PM, on May 27, at 7:00 PM, and on May 28, 2024, at 2:00 PM. Review of MR7 on June 5, 2024, at approximately 11:00 AM, revealed no documentation that the telemetry batteries were changed every 24 hours, as per facility policy. Review of MR9 on June 5, 2024, at approximately 11:30 AM, revealed that the patient was admitted to the hospital on May 28, 2024, at 2:50 PM with a chief complaint of confusion. The patient was admitted and was placed on a telemetry monitor. Further review of MR9 revealed no documentation that the telemetry batteries were changed every 24 hours as per facility policy. During an interview on June 7, 2024, at 11:45 AM, EMP1 confirmed the above findings. .”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42809 Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined the facility failed to follow physician’s orders for a sitter and failed to follow policy and procedures to establish a safe environment for a high-risk suicidal patient, for one of ten medical records reviewed (MR1). Findings include: Review of facility policy “Care of the Patient with Suicide Risk POL-6451697”, last approved 8/15/2023, refers to the “Risk Stratified Response Protocols for the Care of the Patient with Suicide Risk” and the “Environmental Safety Precautions for Patient at Risk of Harming Themselves and Others” documents. Review of “Risk Stratified Response Protocols for the Care of the Patient with Suicide Risk” revealed: “ ... High risk for suicide: Constant Observation will be ordered and implemented ... “. Review of “Environmental Safety Precautions for Patient at Risk of Harming Themselves and Others”, last approved 3/12/2024, revealed: “ ... A thorough safety search is to be conducted with the intent of locating any items which are deemed to be potentially harmful to the patient or staff. ... Remove unnecessary tubing, bandages, and cords from room. ...”. Review of MR1 revealed the patient presented to the emergency department on April 19, 2024, at 5:12 PM, for a voluntary mental health admission with suicidal ideation and a suicide plan. On April 19, 2024, at 5:15 pm, a physcian order was placed for a Constant Observation sitter. Further review of MR1 revealed that on April 16, 2024, at approximately 7:52 PM, the patient was found with no sitter in their room with a call bell wrapped around their neck. The above findings were confirmed by EMP1 and EMP4 during medical record review on May 30, 2024 between 1:00 PM and 2:00 PM.”