Shamrock General Hospital

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 30250 Based in documentation and interview, the facility failed to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. Findings included: Facility policy entitled, “Medical Screening Examinations” REFERENCE NUMBER: 839 stated in part, “POLICY: Patients will be registered upon presentation to the Emergency Department regardless of ability to pay.” Patient # 1 was involved in a single motor vehicle collision with Emergency Medical Services (EMS) arriving on site on 10/05/25 at approximately 0032. EMS transported Patient #1 via ambulance to the facility Emergency Department (ED) around 0100. Review of the ED Logs revealed the following: * Patient #1 was not present on the ED Log of the facility on 10/05/25 or 10/06/25. Patient #1 not being entered into the facility central log for the emergency department was verified on 02/24/26, in interview with the facility administrator.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 30250 Based on a review of documenation and interview, the facility failed to ensure that in the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must-(i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. Findings included: Facility policy entitled, “Medical Screening Examinations” REFERENCE NUMBER: 839 stated in part, “PURPOSE: The purpose of this policy and the Emergency Medical Treatment & Labor Act (EMTALA) medical screening examination (MSE) is to ensure public access to emergency services regardless of ability to pay. POLICY: ... · A Medical Screening Examination (MSE) will be performed by a designated health professional regardless of ability to pay...” Patient # 1 was involved in a single motor vehicle collision with Emergency Medical Services (EMS) arriving onsite on 10/05/25 at approximately 0032. EMS transported Patient #1 via ambulance to the facility Emergency Department (ED) around 0100. Upon arrival in the facility ED with Patient #1 on a stretcher, the ED physician “advised EMS that he was not going to admit the patient to help with care due to the hospital being on diversion for lack of radiology”. The patient was taken to another facility by EMS ambulance for medical screening and treatment. No medical screening examination was documented or performed on this patient. The lack of medical screening exam for Patient #1 was verfied on 02/24/26, in interview with the facility administrator.”

“A Life Safety Code (LSC) survey was conducted at Shamrock General Hospital on 7/1/2025. An entrance conference was conducted on the morning of 7/1/2025 with the Director of Facilities and an additional maintenance employee to discuss the purpose of the LSC compliant and the survey process. The CEO joined for about 5 minutes of into the entrance conference. 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. A LSC exit conference was conducted on the afternoon of 7/1/2025, with the CEO and Director of Facilities. 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.”

“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: 29106 Based on observation and interview during the survey walk of the facility with the Facilities Director on the morning of 7/1/2025, the previous OR suite, sterilizing and decontam rooms are being used as Storage. Not all rooms do not meet the requirements for hazardous area separation. Existing rooms under 250 SF are acceptable. Rooms 250 SF or larger, if sprinklered, must be smoke tight. The doors and walls must be smoke tight, double doors must have astragals, and doors also must have closers.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 29106 Based on review of the records and interview with the CEO and Director of Facilities on the morning of 7/1/2025, the requirement for the fire extinguishment system to be tested at 6 month intervals. Records presented were dated June of 2024 and March of 2025. Begin testing at 6 month intervals and maintain records.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 29106 Based on review of the records and interview with the CEO and Director of Facilities on the morning of 7/1/2025, the requirement for a functioning Fire Alarm system is not met. Zone 3 of the alarm system was giving false alarms. The Fire Marshall put the system out of service June 2025 and Zone 5 was not transmitting to the monitoring facility. It was determined the motherboard needs to be replaced and is obsolete. The system will need to be updated. A fire watch was implemented. Continue reports for 45 days. Send reports the ARU every two weeks and update ARU at 45 days concerning updates in repair time. Monthly fire alarm testing requirement is not being met. The alarm must be verified to be sent to the monitoring station. No alarm logs were available at the time of inspection. Begin monthly log.”

“Operating Features - Other CFR(s): NFPA 101 Operating Features - Other List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features 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 in Form CMS-2567. This Standard is not met as evidenced by: 29106 Based on review of the records and interview with the CEO and Director of Facilities on the morning of 7/1/2025, the requirement for Emergency Preparedness reports for Mock disasters is not met. Real events may substitute for mock drills. The reports provided were from March 2021 Mock Drill, February 24, 2025 Wildfire response, and Jun 17, 2025 Electrical Fire Response and Evacuation. Keep existing reports, participate in community wide disaster drills, and retain after action reports.”

“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: 29106 During the inspection walk with the Director of Facilities on the morning of 7/1/2025, it was observed the requirement for Medical Gas Alarms was not met. A master alarm is required at the Oxygen tank. It appeared there was an area alarm in wing 300, but it is not functional. If not being used, remove panel.”

“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: 29106 Based on review of the records and interview with the Director of Facilities on the morning of 7/1/2025, requirements for a Type 1 electrical system is not met and the facility failed to periodically exercise the Main feeder and circuit breakers. It was indicated that the load switch is broken and cannot be turned of to test the auto start of the generator. The voltage and amp gauges do not work. Equipment items do not come on when the generator is on due to undersize of the old generator. Generator start time is monitored during power outage events. The Director of Facilities indicated the local electrical companies will not perform basic repairs because the electrical system is so old. Records for monthly load tests only included January and March 2025. No other monthly load bank or annual testing records were provided. The existing system is indicated there will be an update in the near future, pending funding. Submit a project to the Architectural Review Unit (ARU) for update to electrical system. “EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the “off” position.” - NFPA 110, 2010, 8.4.7*. Note: “Circuit breakers should be tested under simulated overload conditions every 2 years.” - NFPA 110, 2010, A.8.4.7”

“LICENSURE, CERT., OR REG OF PERSONNEL CFR(s): Staff of the CAH are licensed, certified, or registered in accordance with applicable Federal, State, and local laws and regulations. This Standard is not met as evidenced by: 28422 Based on a review of documentation and an interview with staff, the facility failed to make sure the staff were appropriately certified in CPR, when required by their job description. Findings were: During the review of personnel files on 4-16-25, personnel files for 4 laboratory staff (staff #23-#26) were examined. The job description for the laboratory personnel required current certification in cardiopulmonary resuscitation. None of the 4 staff held the required cardiopulmonary resuscitation, which was confirmed with staff #6 (HR Specialist). The above was confirmed in an interview with staff #1 and other administrative staff on the afternoon of 4-16-25.”

“PERSONNEL CFR(s): (1) Except as specified in paragraph (d)(3) of this section, there must be a doctor of medicine or osteopathy, a physician assistant, a nurse practitioner or a clinical nurse specialist with training or experience in emergency care on call and immediately available by telephone or radio contact, and available on site within the following timeframes: (i) Within 30 minutes, on a 24-hour a day basis, if the CAH is located in an area other than an area described in paragraph (d)(1)(ii) of this section; or (ii) Within 60 minutes, on a 24-hour a day basis, if all of the following requirements are met: (A) The CAH is located in an area designated as a frontier area (that is, an area with fewer than six residents per square mile based on the latest population data published by the Bureau of the Census) or in an area that meets criteria for a remote location adopted by the State in its rural health care plan, and approved by CMS, under section 1820(b) of the Act. (B) The State has determined under criteria in its rural health care plan, that allowing an emergency response time longer than 30 minutes is the only feasible method of providing emergency care to residents of the area served by the CAH. (C) The State maintains documentation showing that the response time of up to 60 minutes at a particular CAH it designates is justified because other available alternatives would increase the time needed to stabilize a patient in an emergency. (2) A registered nurse with training and experience in emergency care can be utilized to conduct specific medical screening examinations only if- (i) The registered nurse is on site and immediately available at the CAH when a patient requests medical care; and (ii) The nature of the patient’s request for medical care is within the scope of practice of a registered nurse and consistent with applicable State laws and the CAH’s bylaws or rules and regulations. (3) A registered nurse satisfies the personnel requirement specified in paragraph (d)(1) of this section for a temporary period if-- (i) The CAH has no greater than 10 beds; (ii) The CAH is located in an area designated as a frontier area or remote location as described in paragraph (d)(1)(ii)(A) of this section; (iii) The State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation on the issue of using RNs on a temporary basis as part of their State rural health care plan with the State Boards of Medicine and Nursing, and in accordance with State law, requesting that a registered nurse with training and experience in emergency care be included in the list of personnel specified in paragraph (d)(1) of this section. The letter from the Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of emergency services in the States. The letter from the Governor must also describe the circumstances and duration of the temporary request to include the registered nurses on the list of personnel specified in paragraph (d)(1) of this section; (iv) Once a Governor submits a letter, as specified in paragraph (d)(3)(iii) of this section, a CAH must submit documentation to the State survey agency demonstrating that it has been unable, due to the shortage of such personnel in the area, to provide adequate coverage as specified in this paragraph (d). (4) The request, as specified in paragraph (d)(3)(iii) of this section, and the withdrawal of the request, may be submitted to us at any time, and are effective upon submission. This Standard is not met as evidenced by: 28422 Based on a review of credentialing files, facility documentation and an interview with staff, the facility failed to provide emergency care necessary to meet the needs of its inpatients and outpatients, as 1 of 2 emergency room, mid-level providers did not possess the appropriate certifications as required of ER physicians by the facility’s CEO. Findings were: In an interview with staff #1 on 4-14-25, providers that work in the emergency department are required to hold current certification in the following: * PALS (pediatric advanced life support) * ACLS (advanced cardiac life support) * BLS (basic life support) The credentialing files for 2 ER mid-level providers were reviewed (staff #11 & #12). Staff #11 held current appointment as Active Status to provide emergency services for the facility. Staff #11’s BLS, ACLS AND PALS certifications had been obtained through an online testing company, which required no in-person, return demonstration of skills. Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, “No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements.” Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541. The above findings were confirmed with the facility CEO on 4-14-25, who concurred that staff #11 were not in possession of the certifications required by the facility.”

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 28422 Based on a tour of the facility and an interview with staff, the facility failed to maintain a premise that was clean and orderly. Findings were: During a tour of the kitchen on 4-16-25, the following was noted: * The formica-topped utility table contained numerous areas of chipped/missing/broken formica finish, leaving the porous plywood underside exposed. This underside cannot be adequately cleaned and can harbor bacteria. * 4 portable fans were being used to circulate air in the kitchen. Portable fans cause dust and debris to become airborne, potentially contaminating food that is being prepared. * 2 of 2 commercial ovens were dirty and caked with what appeared to be splattered grease and food. In an interview with staff #21 (Dietary Director) on 4-16-25, staff #21 stated that the ovens were too hot to clean and remained hot to the touch at all times.\ * A formica-covered shelf contained areas of missing and worn-through finish, exposing the plywood underneath and preventing the surface from being adequately cleaned. The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 4-16-25.”