Douglas County Memorial Hospital-Cah

“PATIENT SERVICES CFR(s): (1) General] (ii) The CAH furnishes acute care inpatient services. This Standard is not met as evidenced by: 50015 Based on observation, record review, and interview, the provider failed to ensure expired patient supplies were removed in one of one labor, delivery, recovery, and postpartum (LDRP) room. Findings include: 1. Observation on 8/18/26 at 2:15 p.m. in the LDRP room revealed a cupboard that contained one pediatric aerosol mask with an expiration date of 7/22/24, one Airlife adult oxygen mask with an expiration date of 7/10/24, one Airlife adult oxygen mask with an expiration date of 4/10/25, one Airlife adult aerosol mask with an expiration date of 7/16/24, and one mask pediatric oxygen mask with seven feet of tubing with an expiration date of 4/10/21. In a bedside table drawer, there was a Yankauer suction handle with a tapered bulbous tip with an expiration date of 10/1/24. 2. Observation on 8/18/26 at 2:27 p.m. of the LDRP closet revealed there were two Airlife adult oxygen mask with an expiration date of 4/10/25. The Neonatal Resuscitation Kit (kit containing specialized medical devices used to help a newborn establish breathing and stable heart rate immediately after birth) table (infant warmer system) had two Amnihook membrane perforators (a sterile, disposable plastic instrument used by healthcare providers to safely rupture the amniotic sac during labor) with an expiration date of 11/1/25, one T-piece resuscitator (a gas powered medical device used to deliver controlled and consistent breathing pressures to newborns and infants) with an expiration date of 5/14/26, two infant SpO2 (percentage of oxygen in the blood) sensors with a use-by date of 10/31/22, two umbilical catheter (a sterile collection of medical tools and tubes used to place a line into a newborn’s blood vessel through the remaining umbilical cord stump) insertion kits that contained two vials of sterile water 10 milliliters (mL) in each with an expiration date of 12/1/24, and two #10 protected disposable scalpel blades with an expiration date of 6/30/24. 3. Review of the provider’s patient room outdates log for 2026 revealed the LDRP room was last checked for expired supplies on 6/17/26 by registered nurse (RN) D. 4. Review of the provider’s 2026 monthly outdates and restocking log for the LDRP closet revealed it was last checked for expired supplies on 7/31/26 by RN D. 5. Interview on 8/18/26 at 3:25 p.m. with RN B revealed that RN D was assigned to check patient rooms for expired supplies and to restock monthly. RN D signed off on the patient room outdate log located in the medication room when he completed that task. If she were to see expired items, she would replace and dispose of the item herself. 6. Interview on 8/19/26 at 4:03 p.m. with purchasing supervisor C revealed the provider did not have a policy regarding expired patient supplies. If patient supplies were expired they should be removed and replaced. RN D performed monthly checks for expired supplies in the patient rooms. 7. Interview on 8/19/26 at 4:20 p.m. with director of nursing (DON) A revealed she expected the expired patient supplies to be removed and replaced from central supply. The staff would only use the supplies in the LDRP room in an emergency, but she expected those supplies to be replaced and not expired. She did not think the provider had an expired supplies policy.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 50915 Based on observation, interview, manufacturer’s instructions for use (IFU), and Association for the Advancement of Medical Instrumentation (AAMI) guidelines, the provider failed to ensure that nine of fifty-two surgical instruments were correctly wrapped with surgical instrument marking tape and that the tape was free from peeling. Findings include: 1. Observation on 8/19/26 at 9:00 a.m. in the emergency department (ED) exam room revealed there were nine of fifty-two sterile instruments with surgical instrument marking tape that was peeling away from the instrument or incorrectly wrapped according to the marking tape manufacturer’s IFU. Three sterile surgical instruments had tape that was peeling away from the instrument. Two sterile surgical instruments had tape that was not wrapped completely around the instrument per the marking tape manufacturer’s IFU. Four sterile surgical instruments were marked with a square piece of tape on one side of their flat surface, not per the manufacturer’s IFU. 2. Interview on 8/19/26 at 9:40 a.m. with purchasing supervisor C revealed that her duties included sterilizing surgical instruments and applying identification tape to the surgical instruments. She was not aware that there were instructions for use of the surgical instrument tape. 3. Interview on 8/19/26 at 9:50 a.m. with lab technician/infection control coordinator (F) revealed that she considered surgical instrument marking tape that was peeling from or incorrectly applied to sterile instruments to be an infection control concern and the instruments should not be used. 4. Review of Key Surgical LLC’s 2024 IFU revealed “Instructions for use: 5. Wrap tape 1.5 times on a stainless-steel instrument. Tape should lay flat without gaps.” “Inspection: Routinely check the instruments during sterile processing. If the tape begins to crack, chip, or peel, remove it entirely.” 5. Review of the 2017 AAMI-ST 79 guidelines, pg. 40 revealed “Instruments should be carefully inspected for flaws, damage, debris, detergent residue, and completeness, then dried. Instrument tape and plastic dipping material, when used properly, are ways of identifying specific instruments. These types of marking products wear out over time and staff need to inspect them each time the instrument is processed, check them for wear according to the IFU of the product used, and replace them as often as needed.””

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 18087 Based on observation, testing, and interview, the provider failed to maintain one hazardous areas (boiler room corridor door) as required. Findings include: 1. Observation on 8/18/26 at 11:30 a.m. revealed the boiler room was in the basement. The corridor door at the top of the stairs was equipped with a closer. Testing of the door at the time of the observation revealed the door would not self-close and latch as required. Interview with the maintenance director at the time of the observation confirmed those findings. He stated there was a fan in the boiler room producing more air pressure than the closer could overcome. The deficiency affected one of numerous requirements for hazardous rooms and had the potential to affect 100% of the occupants of the smoke compartment.”

“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: 18087 Based on record review, observation, and interview, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (flow testing, sprinkler maintenance guidelines). Findings include: 1. Record review on 8/18/26 at 11:45 a.m. revealed the sprinkler maintenance by the outside contractor was performed on 8/26/25 (quarterly), 1/12/26 (quarterly), 3/26/26 (quarterly), and 6/5/26 (annual). The inspections were not been performed on a quarterly timeline as required. 2. Observation on 8/18/26 at 11:55 a.m. revealed there was not a copy of NFPA 25, Inspection, Testing, and Maintenance and Testing of Water-Based Fire Protection Systems available on site. 3. Interview on 8/18/26 at 12:05 p.m. with the maintenance director confirmed those conditions. Failure to continuously maintain the automatic sprinkler system as required increases the risk of death or injury due to fire. The deficiency affected two of numerous requirements for maintenance of the automatic sprinkler system.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 18087 Based on record review and interview, the provider failed to conduct fire drills as required (fire drills not conducted at varied times and transmission of alarm not verified). Findings include: 1. Record review on 8/18/26 at 12:15 p.m. revealed the provider operated with two shifts. Fire drills were required to be conducted monthly under varied conditions. The time of day was one of the conditions that must be varied. *The first shift drills were conducted on July 2025 (no date listed) at 4:00 p.m., on 9/23/25 (no time listed), on 11/25/25 at 11:20 a.m., on 5/26/26 at 4:00 p.m., and on 7/20/26 at 3:30 p.m. in the past year. *The second shift drills (simulated silent drills with no alarm) were conducted on 6/23/25 at 9:00 p.m., on 8/16/25 at 9:30 p.m., on 10/14/25 (no time listed), on 12/23/25 at 7:20 p.m., on 2/25/26 at 2:00 a.m., on 4/20/26 at 11:50 p.m., on 6/29/26 at 12:30 a.m., and on 8/5/26 at 10:50 p.m. since June 2025. There were no fire drill sheets for January 2026 or March 2026. Of the thirteen fire drill sheets reviewed, eight were silent drills and two months were not documented. 2. Record review on 8/18/26 at 2:20 p.m. revealed the fire drill documentation did not include verification of alarm transmission with the time of the signal reception and the name of the monitoring agency contact person who verified the signal reception. The drill sheet simply showed a Y (yes) or N (no) for signal verification. 3. Interview on 8/18/26 at 12:55 p.m. with the maintenance director confirmed the drills and the lack of verification documentation of signal transmission. Failure to conduct fire drills as required increases the risk of death or injury due to fire. The deficiencies affected two of two shifts.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 18087 Based on record review and interview, the provider failed to perform generator maintenance as required. The automated system performed loaded and unloaded testing without load documentation or weekly battery conductivity documentation. Findings include: 1. Record review on 8/18/26 at 11:15 a.m. revealed documentation of diesel generator load runs were for thirty minutes (0.5 hours) each month and only included the date of the run and whether it was run with a load transfer to the generator or not. Interview with the maintenance director at the time of the record review confirmed that finding. Further interview with the maintenance supervisor revealed he was unaware of the necessity of determining whether the load met or exceeded thirty percent of the diesel generator nameplate capacity. No-load calculation was performed in the past three years. While the diesel generator has annual maintenance performed, no documentation was provided, and the annual required no-load bank was last performed in 2024. 2. Record review on 8/18/26 at 11:20 a.m. revealed there was no documentation of the required weekly generator battery conductivity testing. Interview with the maintenance director at the time of the record review confirmed that finding. The deficiencies affected two of numerous generator maintenance requirements.”