Martin County Hospital District

“A life safety code (LSC) full survey was conducted on site on 07/29/2025 - 07/30/2025. An entrance conference was held for the CEO and Director of Quality and Risk Management on 07/29/2025 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 07/30/2025 in the hospital. In attendance was the Director of Quality and Risk Management and Senior Technician. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“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: 35321 K355 - Portable Fire Extinguishers Findings: The surveyor observed, while accompanied by the CEO and Director of Quality & Risk Management, during the hours of the survey from 4:30 pm to 6:30 pm on 07/29/2025 and 7:30 am - 9 am on 07/30/2025, that there were the following issues: 1) Based on observations during the tour, fire extinguisher no. 16 located in Maintenance area had a pressure gauge indicator needle that was pointed in the overcharged zone.”

“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: 35321 K712 - Fire Drills Findings: The surveyor observed, while accompanied by the CEO and Director of Quality & Risk Management, during the hours of the survey from 4:30 pm to 6:30 pm on 07/29/2025 and 7:30 am - 9 am on 07/30/2025, that there were the following issues: 1) Based on review of the records, facility failed to perform fire drills at unexpected times, at least quarterly on each shift. For instance, for the year 2025, majority of drills were conducted during 1st shift between 7 am - 7 pm. The records failed to document whether drills included the transmission of a fire alarm signal. 2) Fire drill participation form evaluation assessment could be improved for readability and comprehension.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 35321 K907 Gas and Vacuum Piped Systems - Maintenance Program Findings: The surveyor observed, while accompanied by the CEO and Director of Quality & Risk Management, during the hours of the survey from 4:30 pm to 6:30 pm on 07/29/2025 and 7:30 am - 9 am on 07/30/2025, that there were the following issues: 1) Based on observations in Vacuum Pump Room, the vacuum pipe support Clevis hanger type all thread was separated from its saddle.”

“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: 35321 K914 - Electrical Systems - Maintenance and Testing Findings: The surveyor observed, while accompanied by the CEO and Director of Quality & Risk Management, during the hours of the survey from 4:30 pm to 6:30 pm on 07/29/2025 and 7:30 am - 9 am on 07/30/2025, that there were the following issues: 1) Based on review of the records, facility did not perform any receptacle maintenance and testing at all in patient care areas. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not. Describe the facility justification of testing frequency (e.g. appropriate testing intervals) based on documented performance data. For example, experiential data shows that retention force of the grounding blade of each electrical receptacle decreases over time due to repeated usage. Thus, the failure rate has a direct correlation to time and usage.”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 51738 Based on observations, record reviews, and interviews, the facility was found to be not in substantial compliance with the Condition of Participation §485.640 Infection Prevention & Control & Antibiotic Stewardship Program, by failing to have active hospital-wide programs for the surveillance, prevention, and control of Hospital Acquired Infections (HAIs) and other infectious diseases; and not addressing issues identified by the programs in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. The facility failed to: 1. Ensure a clean and sanitary environment to avoid sources and transmission of infection. Cross-refer to C1208. 2. Ensure the infection prevention and control professional communicated and collaborated with the Critical Access Hospital’s (CAH’s) QAPI program about infection prevention and control issues. Cross-refer to C1237. 3. Ensure the infection prevention and control professional audited CAH personnel’s adherence to infection prevention and control policies and procedures. Cross-refer to C1240.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 51738 Based on observations, record reviews, and interview, the facility failed to avoid potential sources of infection by not maintaining a clean and sanitary environment. Findings were: During a facility tour on the afternoon of 3/11/25, dust was observed on horizontal surfaces throughout the radiology department and in central supply. A review of Infection Control Minutes and Documents reflected that during environmental rounds in Quarters, 1, 3, and 4, 2024, dust to horizontal surfaces was observed in the radiology department. During an interview, on the afternoon of 3/12/25, Staff #4 (Chief Nursing Officer(CNO)) verified the findings from the facility tour on the afternoon of 3/11/25.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (iii) Communication and collaboration with the CAH’s QAPI program on infection prevention and control issues. This Standard is not met as evidenced by: 51738 Based on a review of facility documents, observations, and interviews, the infection prevention and control professional failed to communicate and collaborate with the CAH’s QAPI program on infection prevention and control issues. Findings were: The facility policy # IC 027 titled “Infection Control Responsibilities” effective 4/19/2020, last reviewed 4/25/2022, reflected: “The Infection Control Nurse ... is responsible for, but not limited to, the following: 2. Implementing policies governing asepsis and infection control. 3. Developing a system for identifying, investigating, reporting, and preventing the spread of infections and communicable diseases among patient and personnel ... ...7. Cooperating with other departments and services in the performance of quality assurance and performance improvement (QAPI) activities. ...” During facility tours with Staff #3 (Director of Quality), and Staff #4 (CNO), on 3/10/25 and 3/11/25, the following was observed: *Expired supplies throughout the facility including physical/occupational/speech therapy (PT/OT/ST), emergency, medical surgical (Med-Surg), radiology, respiratory, surgery, and laboratory departments. These expired supplies included: Intravenous (IV) start kits, gloves, masks, acupuncture needles, extension tubing, chlorhexidine swabs, cleaning wipes, and wound care cleaning solutions. *Opened and unlabeled containers included: -Radiology - opened, single-use package of foam positioning blocks, bulk lots of oxygen extension tubing separated by central supply into individual Ziploc bags dated 11/2024 with no indication what this date is, syringes stored in a cardboard box. -Emergency Department (ED) - open electrode packages in drawers in ED rooms, glucometer control solutions and test trips with no open or discard dates, overfilled sharps container. -Surgery - discolored and degraded pressure infuser bag dated 2016, open Burrette Set package, and an unpackaged single use Pressure Bag on shelf with sterile supplies. -PT/OT/ST - three containers of wound care cleaning solutions on the top of the wound care cart with no open/discard date (two of three were expired), and tube of Medi-honey with patient label in top drawer of wound care cart with no open/discard date. During these facility tours on 3/10/25 and 3/11/25, Staff # 3 (Director of Quality) and Staff #4 (CNO) witnessed and confirmed the above findings. Review of the Infection Control Meeting notes from Q1, Q2, Q3, and Q4 of 2024, reflected that expired supplies had been identified during environmental rounds in all four quarters of 2024. Review of the QAPI minutes notes from Q1, Q2, Q3, and Q4 of 2024 reflected that no Infection Control Meeting findings for 2024 were reported. During an interview, on the afternoon of 3/12/25, Staff #3 (Director of Quality) reported that Infection Control findings have not been reviewed in the QAPI meetings resulting in no action plan being developed to address these findings.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by CAH personnel. This Standard is not met as evidenced by: 31690 Based on observations, interviews, and record reviews the infection prevention and control professional failed to ensure the prevention and control of HAI’s, including adherence to infection prevention and control policies and procedures by CAH personnel. Findings were: During a tour of the therapy department on the afternoon of 3/11/25, the wound care cart was observed in the therapy room where outpatient wound care is performed. During an interview, on the afternoon of 3/12/25, Staff # 7 (Director of Therapy) reported that wound care is performed in this room and the cart is taken to inpatient rooms for wound care. When asked if the cart is taken into all patient rooms regardless of isolation status, he reported that “yes, it is”. Review of facility policy # IC 018 Titled “Non-Critical Medical Equipment, Cleaning of”, effective 4/19/2020, last reviewed 5/6/2022, reflected the following: 1. “Non-critical medical equipment used at... hospital will be maintained in a safe and effective manner to help prevent transmission of infections. 2. It is the responsibility of all healthcare staff using multi-patient equipment e.g., workstations on wheels, vital sign monitors, etc.) to manage, the cleaning and disinfection of these devices... 3. Shared equipment... that is shared between patients will be cleaned before and after every patient, and as needed by the staff using said item... 6. ... At a minimum, non-critical patient care equipment is disinfected when visibly soiled and on a regular basis (between patients or once daily ...).” Review of facility policy # IC 009 Titled “Isolation Precautions, Guidelines for”, Effective 4/9/2020, last revised 10/25/2019, reflected the following: “... 9. Equipment used in the isolation room should remain in the room. 10. Equipment removed from the room should be disinfected with an approved germicidal solution or spray prior to reuse...” During an interview, on the afternoon of 3/12/25, Staff # 3 (Director of Quality) verified these findings.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 31690 Based on record review and interview the facility failed to develop a QAPI Program that included all departments of the CAH. Findings were: Review of the QAPI minutes for 2024 reflected that no findings were reported from Infection Control Meetings for Quarters 1, 2, 3, and 4 of 2024. During an interview, on the afternoon of 3/12/25, Staff #3 (Director of Quality) reported that Infection Control findings have not been reviewed in the QAPI meetings. Therefore, no action plan was developed to address these findings.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 31690 Based on record reviews and interview the facility failed to have a multidisciplinary comprehensive care plan for 4 out of 4 (#1, 2, 3, and 14) swing bed patients reviewed. Findings were: Review of the interdisciplinary team plan documents for patients #1, 2, 3, and 14 reflected that there were no therapy notes related to wound care included in these Interdisciplinary Team (IDT) plans. During an interview on the afternoon of 3/12/25, Staff #4 (CNO) confirmed that all members of the IDT must document their progress on the IDT care plans.”

“SPECIALIZED REHABILITATIVE SERVICES CFR(s): Specialized Rehabilitative Services (§483.65 of this chapter). “ §483.65 (a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for a mental disorder and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident’s comprehensive plan of care, the facility must- (1) Provide the required services; or (2) In accordance with §483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act. (b) Qualifications. Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel. This Standard is not met as evidenced by: 51738 Based on record review and interviews, the facility failed to have physician’s orders for physical therapy-provided wound care, on 4 of 4 swing bed patients (#1, 2, 3, and 14) reviewed. Findings were: Review of the facility policy # Rehab 00001, titled “Rehabilitation Department”, Effective date 5/1/2017, last revised 4/26/2022, reflected the following: “Policy/Criteria: 1. Physical Therapy, Occupational Therapy and Speech Therapy evaluation and treatment services are considered medically necessary when all of the following critera are met... b. The treatment is ordered by an examining physician or appropriate health care provider. ...” Review of swing bed patient charts for patients #1, 2, 3, and 14 revealed that there were no physician orders for wound care. During an interview, on the afternoon of 3/12/25, staff #7 (Director of Therapy) stated that he did not obtain physician orders for wound care that he and other physical therapists provided. He also reported that when he gets an order “to evaluate and treat” he was not required to have additional orders. During an interview, on the afternoon of 3/12/25, staff #4 (CNO) confirmed that prior to providing wound care to patients, physical therapy staff must submit their wound care plan to the provider or physician for approval and orders.”