Ballinger Memorial Hospital

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 35939 . Based on record review and interview the facility failed to maintain in effect a written copy of the plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building, when necessary, as required by NFPA 101, Life Safety Code, 19.7.1. This deficient practice could result in failure to safely and efficiently protect or evacuate patients, staff, and visitors in the event of a fire or other emergency. Record review of the facility’s Emergency Preparedness Plan (EPP) revealed it contained an approved page for signatures of Hospital Personnel. Further record review of the EPP cover page revealed 5 of 6 lines remained blank (not signed). The following lines remained blank/unsigned: Chief of Medical Staff, Chairman of the Board of Directors, Administrators, Director of Employee of Health/Risk Management, and Approval Date. Further review revealed the last time the Emergency Preparedness Plan was reviewed, updated and approved was on 01/29/2024. In an exit interview at approximately 2:55 PM on 05/06/2025, this deficiency was discussed with the Plant Operations Director and the Director of Nursing. The Director of Nursing confirmed the signature and date page needed to be completed by some listed parties. Code Reference(s): NFPA 101, 2012 edition 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. 19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. 19.7.1.3 A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator’s location or at the security center. .”

“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: 35939 . Based on observations and interview the facility failed to maintain smoke barrier walls to resist the passage of smoke as required by NFPA 101, Life Safety Code, 19.3.7 and 8.5. This deficient practice could result in failure to contain toxic products of combustion to all smoke compartments, thus placing the patients, staff, and visitors of multiple smoke compartments in jeopardy in the event of a fire. The inspector observed, while accompanied by the Plant Operations Director on 05/06/2025 from 1:20 PM to 2:45 PM the following: The smoke barrier wall outside the Café & Director of Nutritional Services office had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system. The smoke barrier wall by Storage Room and Linen Closet (around the Café) had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system. The smoke barrier wall by Room 20 (Lab Office) & Room 27 (Patient Room) had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system. The smoke barrier wall by Mammography/Bone Density had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system. The smoke barrier wall by Room 18 (Patient Entrance) & Room 19 (Registration) had unsealed penetrations, penetrations sealed with materials of unknown fire resistivity, and/or sealed in a manner not compliant with a listed firestopping system. In an interview at the time of each finding, The Plant Operations Director was informed of each deficiency and he was able to observe the deficiencies. In an exit interview at approximately 2:55 PM on 05/06/2025, these deficiencies were discussed with the Plant Operations Director and the Director of Nursing. Code Reference(s): NFPA 101, 2012 edition 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. .”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 33326 Based on observation, record review, and interview, the facility failed to keep supplies and medications readily available for emergency cases when, A.) Expired medical supplies were available for use, B.) and the facility did not monitor the temperatures of the radiology department’s medication refrigerator, where the oral contrast was held for CT (computed tomography) scans, to maintain its efficacy. Findings include: A.) An observation, on the morning of 4/21/25, of the facility’s emergency department revealed the following expired medical supplies: (1) Foley Catheter tray with an expiration date of 11/30/2024 (1) Ophthalmic Burr with an expiration date of 8/1/2024 (1) Morgan Medi-Flow lens with an expiration date of 10/28/2024 (1) Lactated Ringer 1000 ml with an expiration date of 7/1/2023 Review of the facility provided document Central Supply Expired Supply Procedure (undated) reflected, “1. Supplies are checked on a monthly basis for date validity. 2. Expired supplies are marked as expired, destroyed, and disposed of. 3. Supplies with valid expiration date is then restocked. During the tour of the emergency department on 4/21/25, Staff #1, Director of Nursing confirmed the findings and removed the items from use. B.) An observation, on the morning of 4/21/25, of the facility’s radiology department revealed the small refrigerator contained (6) bottles of Oral Contrast dye. The package instructions included Store between 0 degrees and 30 degrees Celsius (32 degrees - 86 degrees Fahrenheit). The refrigerator log revealed “Instructions: Log to be maintained for refrigerator in CT room. Radiology tech will record the time and temperature every morning, once daily. If corrective action needs to be taken circle the date and explain action on log.” Review of the log revealed missing temperature checks for May 1,4, 5, 6, 9, 10, 14, 15, 18, 19, 20, and 21. During an interview, in a conference room on the morning of 4/22/24, Staff #3, Radiology Director confirmed the missing refrigerator check dates and stated they should be checked daily.”

“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: 33326 Based on record review, and interview, the facility failed to follow its infection control policy when (1) out of (5) patient suspected of having a highly infections enteric disease was not placed on proper precautions pending diagnostic testing results, this failure places other patients at risk of contracting a communicable disease. Findings include: Review of the facility provided document Synopsis of Types of Precautions and Patients Requiring the Precautions (undated) reflected, “In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment. Examples of such illnesses include: 2. Enteric infections with a low infectious dose or prolonged environmental survival, including, a. clostridium difficile ...In the absence of a physician’s order the charge nurse shall have the authority to initiate isolation procedures as soon as an infections process is suspected.” Review of Patient #1’s Physician’s orders dated 3/28/2025 reflected, “CLOSTRIDIDIUM DIFF ANTEGENS AND TOXIN 1X.” Review of Patient #1’s medical records dated 3/28/2025 reflected, Isolation N/A (not/applicable)” Review of Patient #1’s laboratory ordered test for C diff Toxin and C diff antigen collected 3/30/2025 and reviewed on 3/30/2025 as Negative. During an interview on the afternoon of 4/22/2025, in an administrative office, Staff 4, RN confirmed the patient had orders to check for C diff and the patient needed to be placed on contact isolation until the results came back negative.”