Lifescape

“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: 52836 Based on observation and interview, the facility failed to protect medical gas storage as required. Oxygen cylinders were not stored with the required precautions. Findings include: 1. Observation on 6/24/25 at 1:35 p.m. in the oxygen storage room with Vice president J revealed two full D-size oxygen cylinders were stored upright outside of the oxygen cylinder storage rack. One C-size oxygen cylinder was found housed within a fabric case and was lying on the floor beside the oxygen cylinder storage rack. Vice president J agreed that the cylinders were stored improperly. The deficiency affected one of one smoke compartments.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46511 Based on record review, interview, and policy review, the provider failed to ensure patient’s care plans had been implemented upon admission and documented on 1 time per shift for 29 of 30 sampled patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, and 30) medical records. Findings include: 1. Review of the above listed patient’s medical records revealed: *Patient 1 had: -Been admitted on 12/30/24 with a diagnosis of respiratory failure (when the lungs can’t properly exchange gases) of a preterm infant. -A care plan that had been initiated and documented on 12/30/24. -Care plans that had not been updated or documented from 12/31/24 through 1/6/25 and 1/16/25 through 1/31/25. *Patient 2 had: -Been admitted on 6/6/25 with a diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disease (inflammatory disease that affects the central nervous system) and autism disorder (neurological disorder that affects how people communicate, learn, and behave). -A care plan that had been initiated and documented on 6/7/25. -Care plans that had not been updated or documented on 6/9/25, 6/10/25, and 6/11/25. -Discharged on 6/16/25. *Patient 3 had: -Been admitted on 11/5/24 with a diagnosis of anoxic brain injury (when the brain doesn’t receive enough oxygen). -A care plan that had been initiated and documented on 11/7/24. *Patient 4 had: -Been admitted on 4/10/24 with a diagnosis of prematurity and bronchopulmonary dysplasia (lung condition that affects premature babies with breathing problems and oxygen needs). -A care plan that had been initiated and documented on 4/11/24. -Care plans that had not been updated or documented from 5/26/25 through 6/8/25. *Patient 5 had been admitted on 2/27/23 with a diagnosis of prematurity and Pallister-Killian syndrome (genetic disorder caused by an extra chromosome). -The patient’s only care plans were initiated and documented on 11/13/24 and 6/16/25. *Patient 6 had been admitted on 2/10/21 with a diagnosis of riboflavin transporter deficiency (progressive neurodegenerative disease). -The patient’s initial care plan was initiated and documented on 2/12/24. *Patient 7 had: -Been admitted on 2/3/22 with a diagnosis of chronic respiratory failure and tracheomalacia (cartilage in the windpipe is weak or floppy). -A care plan that had been initiated and documented on 2/13/24. -Care plans that had not been updated or documented from 5/26/25 through 6/5/25. *Patient 8 had: -Been admitted on 4/17/24 with a diagnosis of a chromosomal abnormality. -A care plan that had been initiated and documented on 4/1/25. -Care plans that had not been updated or documented from 5/26/25 through 6/5/25. *Patient 9 had been admitted on 6/5/25 with a diagnosis of chronic respiratory failure (when the lungs can’t adequately oxygenate the blood or remove carbon dioxide) and prematurity. -The patient’s initial care plan was initiated and documented on 6/16/25. *Patient 10 had: -Been admitted on 5/21/24 with a diagnosis of severe hypoxic-ischemic encephalopathy (condition resulting from insufficient blood and oxygen flow to the brain) and fetal alcohol syndrome (condition that results from alcohol exposure during the mother’s pregnancy). -A care plan that had been initiated and documented on 5/24/24. -Care plans that had not been updated or documented from 5/30/25 through 6/4/25. *Patient 11 had: -Been admitted on 8/15/23 with a diagnosis of severe hypoxic-ischemic encephalopathy. -A care plan that had been initiated and documented on 2/13/24. -Care plans that had not been updated or documented from 5/26/25 through 6/2/25. *Patient 12 had: -Been admitted on 1/19/21 with a diagnosis of respiratory failure. -A care plan that had been initiated and documented on 2/12/24. -Care plans that had not been updated or documented from 2/12/24 through 4/19/24 and from 5/26/25 through 6/13/25. 18559 *Patient 13 had: -She had been admitted on 8/30/23 with a diagnosis of glutaric acidemia, type 1 (metabolic disorder causing the body to have trouble breaking down amino acids). -A care plan had been initiated and documented on 2/13/24. -Care plans had not been updated and documented on 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25 and 3/23/25 for the last 3 weeks of the patient’s admission. *Patient 14 had: -He had been admitted on 3/30/23 with a diagnosis of short bowel syndrome (shortened small intestine making difficult to absorb nutrients). -A care plan had been initiated and documented on 3/30/23. -Care plans had not been updated and documented on 5/5/25, 5/16/25, and 5/17/25 for the last 3 weeks of the patient’s admission. *Patient 15 had: -He had been admitted on 3/28/25 with a diagnosis of aspiration pneumonia (lung infection caused by inhalation of liquid into the lung). -A care plan had been initiated and documented on 3/28/25. -Care plans had not been updated and documented from 4/5/25-4/10/25 for the last 3 weeks of admission. *Patient 16 had: -She had been admitted on 3/14/25 with a diagnosis of B-Cell acute lymphoblastic leukemia (type of blood cancer that too many immature B-Cells have been produced by the bone marrow). -A care plan had been initiated and documented on 3/15/25. -No care plans that had been updated and documented from 3/17/25 through her discharge date of 3/21/25. *Patient 17 had: -He had been admitted on 2/14/25 with a diagnosis of Di George Syndrome (genetic disorder caused by a missing piece of chromosome 22). -A care plans had been initiated and documented on 2/18/25. -The patient’s only updated and documented care plan was on 2/20/25. *Patient 18 had: -He had been admitted on 1/7/25 with a diagnosis of prematurity (baby born before 37 weeks of pregnancy). -A care plan had been initiated and documented on 1/8/25. -Care plans had not been updated and documented from 1/9/25 through 1/30/25. -He had been discharged on 2/18/25. *Patient 19: -He had been admitted on 12/17/24 with a diagnosis of a subdural hematoma (condition where blood collects between the brain and its outer covering). -A care plan had been initiated and documented on 12/18/25. -Care plans had not been updated and documented on 12/22/24, 12/23/24, 12/25/24, and 12/26/24. 50715 *Patient 20 had: -Been admitted on 11/12/24 with a diagnosis of status post motor vehicle accident (MVA) with traumatic brain injury (TBI) (brain injury from a violent blow or jolt to the head) and was discharged on 12/13/24. -A care plan had been initiated and documented on 11/13/24. -Care plans had not been updated or documented on 11/20/24, 11/23/24, 11/27/24 through 12/1/24, and 12/10/24. *Patient 21 had: -Been admitted on 12/2/24 with a diagnosis of status post MVA and spinal cord injury (damage to the spinal cord) and was discharged on 12/13/24. -A care plan had been initiated and documented on 12/3/24. -Care plans had not been updated or documented on 12/8/24 and 12/10/24. *Patient 22 had: -Been admitted on 11/18/24 for respiratory failure and was discharged on 11/27/24. -A care plan had been initiated and documented on 11/18/24. -Care plans had not been updated or documented on 11/20/24 and 11/23/24. *Patient 23 had: -Been admitted on 11/9/24 with a diagnosis of status post meningitis (inflammation of brain and spinal cord), epilepsy (seizures), and stroke (blood flow to the brain is interrupted) and was discharged on 11/15/24. -A care plan had been initiated and documented on 11/9/24. -Care plans had not been updated or documented on 11/11/24. *Patient 24 had: -Been admitted on 10/29/24 with a diagnosis of status post MVA and was discharged on 11/14/24. -A care plan had been initiated and documented on 10/30/24. -Care plans had not been updated or documented on 10/31/24 through 11/3/24,11/5/24 through 11/10/24, and 11/12/14 through 11/14/24. *Patient 26 had: -Been admitted on 9/18/24 with a diagnosis of status post fall from a ladder and TBI and was discharged on 10/3/24. -A care plan had not been initiated or documented on until 9/24/24. -Care plans had not been updated or documented on 10/1/24 and 10/2/24. *Patient 27 had: -Been admitted on 9/23/24 related to a brain tumor and required a resection of her ventricular shunt (device that drains fluid from the brain) and was discharged on 10/3/24. -Her initial care plan had been documented on 9/23/24. -Care plans had not been documented on 10/1/24 through 10/3/24. *Patient 28: -He had been admitted on 8/30/24 related to a brain mass and difficulty with speech and discharged on 9/27/24. -A care plan had not been initiated or documented on until 9/7/24. -Care plans had not been updated or documented on 9/9/24, 9/11/24, 9/12/24/ 9/14/24, 9/16/24, 9/18/24, and 9/20/24 through 9/23/24. *Patient 29 had: -Been admitted on 9/13/24 with a diagnosis of a respiratory illness and generalized weakness and was discharged on 9/23/24. -A care plan had not been initiated or documented on until 9/15/24. -Care plans had not been updated or documented on 9/16/24 through 9/18/24 and 9/20/24 through 9/23/24. *Patient 30 had: -Been admitted on 7/25/24 with a diagnosis of status post fall from a horse and an L3 burst fracture (spinal injury where the third lumbar vertebra (L3) in the lower back is fractured due to a forceful compression), and leg weakness and was discharged on 8/6/24. -A care plan had not been initiated or documented on until 7/27/24. -Care plans had not been updated or documented on 7/28/24 and 7/29/24. Interview on 6/17/25 at 3:30 p.m. with nurse manager E regarding nursing care plan documentation revealed: *Care plans should have been initiated by the nursing staff upon a patient’s admission to the hospital. *Care plans should have been updated and documented on regarding the patient’s progress one time per shift daily by the nursing staff until the patient discharged. *She agreed with the above findings. Interview on 6/18/25 at 8:00 a.m. with director of nursing A regarding nursing care plan documentation revealed: *Care plans should have been initiated by the nursing staff within 24 hours of a patient’s admission. *Care plans should have been documented on once per shift by the nursing staff until the patients were discharged. Review of the provider’s June 2025 Admission Assessment policy revealed: *”An initial care plan will be implemented upon [a patient’s] admission (within 24 hours) to the Specialty Hospital. *The [patient’s] care plan should be documented on a minimum of 1 x [time] per shift.” Review of the provider’s 6/2025 Care Plan Preparation Procedure and Checklist revealed, “Care plans should be completed within 24 hours of [a patient’s] admission, and charted on a minimum of 1 x per shift.””

“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: 50715 Based on observation, interview, policy review, employee files review, and manufacturer’s instructions for use (IFU) review, the provider failed to ensure: *One of one Lifepak 20e (defibrillator) had been checked daily per the manufacturer’s IFU. *Staff on duty had been properly trained to operate and perform the required daily checks on the Lifepak 20e. Findings include: 1. Observation and interview on 6/16/25 at 11:00 a.m. with registered nurse (RN) B and RN C in the acute inpatient area by the nurse’s station revealed: *A Lifepak 20e defibrillator was located on top of the crash cart. *RN B stated the defibrillator printed out a daily test that was to be attached to the daily checklist and marked off as completed. -That had been their only process for the daily checks of the defibrillator. *RN C stated, “We do not touch the machine. We would not use the Lifepak, we only use the AED” [automatic external defibrillator]. *RN B and RN C stated they had not performed other checks on the defibrillator as they do not operate the machine unless they have a physician’s order to. *RN B stated some physicians used the defibrillator to monitor a patient’s heart rhythm if requested. *RN B stated she was unsure why the provider had both a defibrillator and an AED. *RN B confirmed staff had not performed the steps according to the manufacturer’s IFU for checking the Lifepak 20e defibrillator. Interview on 6/16/25 at 11:25 a.m. with director of nursing (DON) A regarding the Lifepak 20e defibrillator revealed: *She had thought the provider needed to have both a defibrillator and an AED available for use. *She stated that if the physician had been in the building, the staff would have used the Lifepak defibrillator per the direction of the physician. *She had been unaware their checklist had not followed the manufacturer’s IFU. Interview on 6/17/25 at 9:15 a.m. with DON A and vice president (VP), medical and therapy services F revealed: *DON A confirmed the Lifepak 20e defibrillator was brought into the hospital in 2019. *An educational in-service had been provided to the staff from Medtronic (medical device company), but no additional training had been provided on the use of the defibrillator since. *DON A and VP, medical and therapy services F agreed staff should have had the proper training to have operated and maintained the defibrillator according to the manufacturer’s IFU. *Review of the provider’s Daily Crash Cart Checklist revealed a section for staff to document the defibrillator check but it had not included the additional instructions as directed by the manufacturer’s IFU. Review of the provider’s 10/27/2022 Emergency-Code Blue policy revealed: “All staff will be instructed on the proper method for obtaining emergency medical services during the first day of employment and annually thereafter.” Review of the provider’s 4/16/2024 Crash Cart and Emergency Medication/Supplies policy revealed: *”Crash carts are checked a minimum of monthly to ensure the following: -Fisher Coon Monthly Crash Cart Checklist: --Defibrillator with electrodes.” Review of the provider’s undated Code Blue Medical Response annual education pg. 13 revealed: *”First Person On The Scene: -Follow your training, call for medical response, assess the situation, and begin CPR if needed. -Help ensure the area is safe, get the AED, call 911 if needed, help with compressions if trained.” Review of the manufacturer’s 2019 IFU for the Lifepak 20e Defibrillator/Monitor Operator’s Checklist revealed: *”1. Check printed result of 3 A.M. daily auto test. *2. Inspect physical condition for: -Foreign substances. -Damages or cracks. *3. Inspect power source *4. Check therapy and ECG electrodes for: -Use by date. -Spare electrodes [are] available. *5. Examine accessory cables for: -Cracking, damage, broken or bent parts or pins, and paddle surfaces for pitting. *6. Disconnect the defibrillator from AC power, wait 2 seconds, press ON and check for: -Momentary SELF-TEST messages, illumination of LEDs, and speaker beep. -Services LED is lit. *7. Check ECG printer for: -Adequate paper supply. -Ability to print. *8. Confirm [the] therapy cable [is] connected to defibrillator to perform [the] cable check: -If QUIK-COMBO therapy cable is connected: --Confirm [the] test plug [is] connected to [the] therapy cable. --Press ANALYZE button. --After ANALYZING NOW message, look for REMOVE TEST PLUG message. *9. Reconnect to AC power and then power off the device.” 18559 Review of the employee files for DON A, RN C, RN/care coordinator G, RN H, and RN I revealed there was no documentation that they had completed training to safely operate and maintain the defibrillator during their orientation or annual training.”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 50715 Based on observation, interview, refrigerator/freezer logs review, and policy review, the provider failed to ensure the temperatures of two of two medication refrigerators/freezers had been monitored and documented on daily per hospital policy. Findings include: 1. Observation on 6/16/25 at 10:10 a.m. in exam room 1205 revealed: *A refrigerator containing a single vial of tuberculin purified protein derivative (medication used to diagnose tuberculosis). *There were no documented temperatures for June 2025 for the shifts on: -June 1, a.m./p.m. (morning/evening). -June 3, a.m. -June 4 through June 6, p.m. -June 7 through June 11, a.m./p.m. -June 12, p.m. -June 13, through June 15, a.m./p.m. *In May 2025, there were no documented temperatures the shifts on: -May 1, p.m. -May 3, a.m./p.m. -May 4, a.m./p.m. -May 5, through May 8, p.m. -May 10, a.m./p.m. -May 11, a.m./p.m. -May 12, p.m. -May 14, p.m. -May 17, a.m./p.m. -May 18, a.m./p.m. -May 20, p.m. -May 21, a.m. -May 22, p.m. -May 23, p.m. -May 24, through May 26, a.m./p.m. -May 27, through May 30, p.m. -May 31, a.m./p.m. Interview on 6/16/25 at 10:25 a.m. with registered nurse (RN) B revealed she: *Confirmed staff working in the acute care setting had not been documenting the temperatures of the refrigerator in the exam room. *Stated that refrigerator stored vaccines for patients. *Stated patients in the acute care setting could have received the vaccines that had been stored in the refrigerator. *Confirmed vaccines required daily monitoring and documentation of temperatures. 2. Observation and interview on 6/16/25 at 11:00 a.m. in medication room 1206 with RN C revealed: *A single refrigerator/freezer containing multiple patients’ medications. *She stated the temperatures were to be checked and documented daily by the night staff nurse. *The June 2025 temperature log indicated: -June 8 had no documented refrigerator temperature. -June 9 had no documented refrigerator or freezer temperatures. -June 12 had no documented refrigerator or freezer temperatures. *RN C confirmed the above findings and agreed there had been gaps in temperature monitoring for the medication refrigerator and freezer. Interview on 6/16/25 at 11:25 a.m. with director of nursing A regarding the temperature monitoring and documentation for the refrigerators and freezer medication and/or vaccines were stored revealed: *The staff assigned to monitor and document the temperatures for the vaccine refrigerator had not been documenting on the weekends. *Staff who worked in the inpatient acute setting had not been assigned to monitor and document the temperatures of the vaccine refrigerator located in exam room 1205. *She had not been aware that the temperatures had not been monitored and recorded twice a shift for multiple days both in the a.m. and p.m. for the refrigerator where vaccines were stored. *She agreed the temperatures of the vaccine refrigerator should have been monitored twice a day/seven days per week. *She agreed the temperatures of the refrigerator and freezer containing patient medications in medication room 1206 should have been monitored and documented daily to ensure the safety and efficacy of the medications. Review of the provider’s undated Temperature Log for Refrigerator storing vaccines revealed, “1. Record the A.M. and P.M. temperatures each workday. Note the exact time of each temperature reading and the initials of the reader.” Review of the provider’s 10/2024 Storage of Drugs and Biologicals policy revealed, “The temperature will be checked and recorded once every twenty-four (24) hours.””