Eagleville 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: 51039 Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of two levels. Findings include: Observation on May 12, 2025, at 11:50 a.m., revealed a sprinkler missing its escutcheon plate, Admissions Office next to supply closet. Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the missing escutcheon.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 51039 Based on observation, interview, and document review, it was determined the facility failed to ensure fire alarm inspectors were certified, affecting the entire facility. Findings include: Document review on May 12, 2025, at 8:30 a.m., revealed the facility could not provide certification documentation for the inspector that performed the facility’s annual portable fire extinguisher inspection in June 2024. Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the missing documentation.”

“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: 51039 Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barrier walls, affecting one of two levels. Findings include: Observations on May 12, 2025, revealed unsealed penetrations of smoke barrier walls in the following locations: a. 12:25 p.m., open penetrations above entry smoke door, on the first floor, Acute Psychology Unit; b. 12:45 p.m., open penetration above entry smoke door labeled #34, on the second floor, D2 West. Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the smoke wall penetrations.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 51039 Based on document review and interview, it was determined the facility failed to maintain and test the generator, affecting the entire facility. Findings include: Document review on May 12, 2025, at 8:30 a.m., revealed the facility could not produce documentation of the Annual Fuel Quality Test. Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the missing fuel quality report.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 39640 Based on observation and interview it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of two levels. Findings include: Observation on May 12, 2025, at 12:30 p.m., revealed a refrigerator plugged into a power strip, the first EVS Administration office. Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the unauthorized electrical device.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 39640 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of medical gas rooms, in sprinklered locations, affecting one of two levels. Findings include: Observation on May 12, 2025, at 11:20 a.m., revealed, on the first floor, in room 112 Oxygen Storage Room door lacked a self-closer. Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the oxygen storage door deficiency.”

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h) A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation .... This Standard is not met as evidenced by: 46816 Based on facility policy and interview with staff (EMP), it was determined that the facility failed to ensure patient rights were followed regarding allowance of in-person visitation for hospitalized patients. Findings include: A review on April 7, 2025 of the facility “General Handbook ... Resident Rights and Responsibilities”, no date, revealed “Visitation- You have the right to: Decide if you want visitors or not while you are here ... Designate those persons who can visit you during your stay. These individuals do not need to be legally related to you.” A review on April 7, 2025 of “General Handbook” revised February 6, 2025, revealed “Due to COVID-19 Pandemic The following modifications apply to the handbook: ... 2. Visitation is suspended at this time.” Interview on April 7, 2025 at 2:40 PM with EMP1, confirmed “We don’t allow on-site visitation from family or friends of patients. We do ZOOM or phone calls”. Further interview confirmed “in-person visitation has not been allowed since COVID restrictions were put into place a few years ago”.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44109 The information reviewed during the unannounced special monitoring survey on November 16, 2023, provided evidence the facility failed to substantially comply with this condition of participation by failing to provide a safe environment for a patient on a Detox Unit. Video surveillance clearly showed a staff member completing rounds inconsistent with established facility policies and procedures. A discussion took place with the survey team and the facility’s administrative staff (EMP7), (EMP9), and (EMP10) regarding the survey team’s concerns related to Patient’s Rights on November 16, 2023, at 5:29 PM. Cross reference §482.13 (c)(2) Patient Rights: Care in a Safe Setting”

“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: 44109 Based on review of facility security video, policy and procedures, facility documents, medical records (MR) and interviews with staff (EMP) it was determined the facility failed to maintain a safe setting for patients on a Detox Unit. Review on November 15, 2023, of security footage D’Arclay 2 East Hallway, revealed, on October 27, 2023, at 2:28 PM, PT1 is observed entering their room, and after this time (2:28 PM), PT1 is not observed out of their room. At 5:00 PM EMP8 is observed walking past the doorway of PT1’s room to open the door of the unit for another staff member. At 5:01 PM, EMP8 is observed outside the doorway of PT1’s room and does not enter the room. At 5:35 PM, EMP8 is observed walking into PT1’s room. At 5:36 PM EMP8 is observed to leave the room to find another staff member and they both enter PT1’s room. Review on November 15, 2023, of facility policy, “Patient Safety Rounds-15 Minute, 30 Minute and Hourly” Revised July 2022, revised July 2022, revealed, “...PURPOSE: To establish levels of patient safety round and observation that provide each patient with optimal level of safety in the least restrictive manner, depending on their level of care and nursing unit ....30 Minute Rounding Responsibilities (Detox Units D’Arclay 2 east and D’Arclay 2 West Units ...During waking hours, observations should include “checking in” with the patient verbally to ensure their safety and well-being and identify any needs they may have or need for further assessment of intervention ...Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress ...Observations may not be completed standing in doorway or at a distance particularly for patient who are sleeping. It is expected that staff will enter the room, approach the patient and check their identity, respirations and ensure they are not in any distress ...If a patient is asleep, face and chest movement must be visualized. Review of facility document, “Resident Rights and Responsibilities” revised July 2021, revealed, “...As our Resident, you have the right to safe, respectful, and dignified care at all times...” Review on November 15, 2023, of MR1’s Nurse Progress Note revealed on October 27, 2023, at 6:00 PM, Patient found in bed unresponsive to verbal and touch stimuli. Nurse was unable to find patient’s pulse. CPR was initiated and Narcan was administered twice with no effect. Review on November 15, 2023, of MR1’s Nurse Progress Note revealed on October 27, 2023, at 9:44 PM revealed, at 5:50 PM police and paramedics arrived on-site to continue life saving measures. At 6:03 PM Paramedics discontinued life saving measures. Interview with EMP7 on November 15, 2023, at 2:07 PM confirmed on October 27, 2023, at 5:01 PM, EMP8 did not enter PT1’s room and EMP8 completed rounding from the doorway. Further interview with EMP7 confirmed the rounds completed for PT1 on October 27, 2023, at 5:01 PM did not follow established facility policy and procedures.”