Hamilton Hospital

“A life safety code (LSC) survey was conducted onsite at the facility on 05/06/25 and 05/07/25. An entrance conference was held on 05/06/2025 with the Maintenance supervisor and Chief Operating Officer to discuss the purpose of the unannounced LSC onsite visit and the survey process was explained. 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 05/07/25 at the hospital. In attendance were the facility’s Maintenance supervisor and Chief Operating Officer. The preliminary findings of the survey and the next steps of 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.”

“Multiple Occupancies - Contiguous Non-Health CFR(s): NFPA 101 Multiple Occupancies - Contiguous Non-Health Care Occupancies Non-health care occupancies that are located immediately next to a Health Care Occupancy, but are primarily intended to provide outpatient services are permitted to be classified as Business or Ambulatory Health Care Occupancies, provided the facilities are separated by construction having not less than 2-hour fire resistance-rated construction, and are not intended to provide services simultaneously for four or more inpatients. Outpatient surgical departments must be classified as Ambulatory Health Care Occupancy regardless of the number of patients served. 18.1.3.4.1, 19.1.3.4.1 This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to maintain the 2-hour fire resistance rated wall between the health care occupancy of the hospital and the business (non-patient care) occupancy, in accordance with NFPA 101, 19.1.3.4.1. This failure could allow the transfer of fire/smoke and affect the safety of the building’s occupants in the event of a fire or emergency. Findings included: During observations and interviews on 05/06/25 from 4:55 p.m. to 5:00 p.m., the fire-rated wall between the health care and business occupancies in the hospital had above the doors (on the hallway connector side): a ½ inch hole around a flexible conduit penetration, 1-inch hole around another flexible conduit penetration, a 1-inch hole around a low voltage wire penetration. The maintenance supervisor said this fire-rated wall was the wall that separated the older portion of the hospital (non-patient use) from the patient care side and confirmed the observations when the surveyor discussed the finding.”

“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: 31958 Based on observation and interview, the facility failed to ensure 1 of 1 hazardous mechanical room (off the main corridor past the surgical suite) was protected with a 1-hour fire rated fire barrier, in accordance with NFPA 101, 19.3.2.1. This failure could allow the transfer of fire/smoke and affect the safety of the building’s occupants in the event of a fire or emergency. Findings included: During observations and interviews on 05/06/25 from 4:20 p.m. to 4:30 p.m., in the mechanical room containing gas-fired boilers, the room’s fire-rated concrete masonry block wall separating it from the corridor had the following unsealed openings in it near the ceiling: 1 flex conduit penetration, 1 rigid conduit penetration, 2 hot water plumbing pipe penetrations, a group of 4 additional rigid conduit penetrations, and 2 additional flexible conduit penetrations. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“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: 31958 Based on observation and interview, the facility failed to maintain sprinkler heads free of foreign material in the dietary kitchen in the hospital, in accordance with NFPA 25, 5.2.1.1.2(5). This failure could delay activation of fire sprinkler heads in the event of a fire, allow a fire to spread, and adversely affect the safety of the building’s occupants in the event of a fire. Findings included: During observations and interviews on 05/07/25 from 9:55 a.m. to 10:00 a.m., in the dietary kitchen, all 10 fire sprinkler heads around the cooking, preparation and ware washing area were loaded with dust. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“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: 31958 Based on observation, interview, and record review, the facility failed to ensure 52 of 52 portable fire extinguishers throughout the facility had monthly inspections performed, in accordance with NFPA 101, 19.3.5.12, 9.7.4.1 and NFPA 10, 7.2.1.2. This failure could affect the reliability/function of portable fire extinguishers to extinguish a fire in an emergency, could allow a fire to spread, and adversely affect the safety of the building’s occupants. Findings included: During observations and interviews on 05/06/25 from 2:00 p.m. to 5:15 p.m., the tags on portable fire extinguishers were inspected and indicated the last annual service inspection was conducted during September 2024. None of the observed fire extinguisher tags contained evidence that monthly (quick check) inspections were performed for the months of October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, and April 2025. The maintenance supervisor said there were 52 total fire extinguishers in the hospital and that additional written records were kept of monthly inspections. Review of available maintenance records for monthly inspections of fire extinguishers only included the months of January through May for the year 2024.”

“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: 31958 Based on observation and interview, the facility failed to ensure 2 of 2 smoke barrier walls (one dividing the patient rooms and another between the separating the patient room from the imaging rooms and support spaces) were constructed to least a ½-hour fire resistance rating and all penetrations sealed, in accordance with NFPA 101, 19.3.7.3. This failure could allow fire/smoke to spread from one smoke compartment to another, and adversely affect the safety of the building’s occupants in the event of a fire or emergency. Findings included: During observations and interviews on 05/07/25 from 10:05 a.m. to 10:35 a.m., the smoke barrier wall by the doctor’s lounge and room 141 had above the corridor ceiling, a 1-inch hole in the wall and an electrical conduit sealed with a foam product (could not be verified for use in fire resistance rated walls). The smoke barrier wall above the corridor doors (on the nurse station side) had openings around 5 low voltage wire penetrations. The portion of the smoke barrier wall that ran along the IT closet was not sealed to the underside of the roof deck, had openings in the wall, unsealed penetrations from structural members, openings around a bundle of electrical conduit, and scab patches present in the gypsum board wall. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to a door located in 1 of 2 smoke barrier walls (the one dividing the patient rooms) was self or automatic-closing, in accordance with NFPA 101, 19.3.7.8(1). This failure could allow fire/smoke to spread from one smoke compartment to another, and adversely affect the safety of the building’s occupants in the event of a fire or emergency. Findings included: During observations and interviews on 05/07/25 from 10:05 a.m. to 10:35 a.m., the smoke barrier wall that ran along the toilet room in the doctor’s lounge had a door that was not equipped with a self or automatic closing device. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“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: 31958 Based on interview and record review, the facility failed to conduct fire drills at least quarterly on each shift, in accordance with NFPA 101, 19.7.1.4 through 19.7.1.7. This failure could delay staff response in the event of a fire or emergency and potentially adversely affect the safety of the building’s occupants. Findings included: During interviews and record reviews on 05/07/25 from 8:30 a.m. to 12:00 p.m., the only documentation available for fire drills conducted in the facility were for April 2024 and October 2024. During the exit interview, the chief operating officer said the hospital had two twelve hour shifts for staff. The surveyor provided an opportunity for additional fire drill records, but none were provided. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 31958 Based on interview and record review, the facility failed to provide a documented categorical risk assessment, in accordance with NFPA 99, Chapter 4. This failure could compromise the hospital’s building systems and could adversely affect the safety of the patients in the event such systems failed. Findings included: During interviews and record review on 05/07/25 from 8:30 a.m. to 12:00 p.m., the facility’s records did not include a documented categorial risk assessment based on the facility’s systems (essential electrical system, information technology and communications, plumbing, and mechanical) and their possible failure and potential effect on the delivery of healthcare services for a hospital. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“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: 31958 Based on interview and record review, the facility failed to test electrical receptacles at patient care areas at internals not exceeding 12 months, in accordance with NFPA 99, 6.3.4. This failure could result in issues with the electrical system and adversely affect the safety of the patients. Findings included: During interviews and record reviews on 05/07/25 from 8:30 a.m. to 12:00 p.m., the facility’s records did not include any documentation that electrical receptacles at patient care areas were tested at any interval. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“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: 31958 Based on observation, interview, and record review, the facility failed to maintain 2 of 2 generators (one interior and one exterior) that provided emergency power to the facility as follows: *Testing was not conducted under load at least monthly for at least 30 minutes, including operating the transfer switches, in accordance with NFPA 110, 8.4, 8.4.1, 8.4.2, *The time delay to transfer to emergency power, delay to restoration to normal power, and delay on shutdown were not recorded in the generator testing logs, in accordance with NFPA 110, 8.4.5. *A 4-hour loaded test every 36 months was not performed, NFPA 110, 8.4.9. This failure could affect the reliability of the emergency power system during a power outage and potentially adversely affect the safety of the building’s occupants. Findings included: During observations, interviews, and record reviews on 05/06/25 from 3:30 p.m. to 4:30 p.m. and on 05/07/25 from 8:30 a.m. to 12:00 p.m., two separate generators (one interior and one exterior) and their automatic transfer switches were installed that provided emergency power to the hospital. Available generator testing logs available only indicated a run time of 12 minutes each week, with no transfer time to emergency power, delay to restoration to normal power, and delay on shutdown, or indication that the generator was under load when tested. There was no documentation that a 4-hour load test was conducted every 36 months. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“RECORDS SYSTEM CFR(s): All orders of doctors of medicine or osteopathy or other practitioners, reports of treatments and medications, nursing notes and documentation of complications, and other pertinent information necessary to monitor the patient’s progress, such as temperature graphics, progress notes describing the patient’s response to treatment; and This Standard is not met as evidenced by: 39057 Based on record review and interview, the facility failed to ensure 4 patients (Patients #4, #6, #8, #27) out of 30 patients had a history and physical (H&P) examination within 24 hours of admission. Finding Included: 1) Record review of Face Sheet and Patient Progress Notes (nursing) dated 04/10/2025 reflected Patient #4 (current patient) was a 58 year old female, with history multiple knee surgeries and allergies to tape, plastic, penicillin, iodine, and betadine. Patient records reflected she was transfer from outside facility to swing bed on 04/07/2025 at 12:28 pm for post knee surgery. Last H&P provided was dated 03/31/2025 and 04/03/2025 operative report from Medical City Dallas. As of 04/10/2025 at 10:15 am, no H&P or physician progress notes were found in patient’s record. 2) Record review of Face Sheet, Patient Progress Notes (nursing) dated 04/10/2025, and ER Visit Note dated 04/06/2025 reflected patient #6 (current patient), a 70 year-old male with history of cancer of the liver, cirrhosis of liver, paralysis of diaphragm, sleep apnea, hypertension, and pulmonary edema. Patient records reflected admission to medical inpatient from emergency department on 04/08/2025 at 1:15 pm for cellulitis of lower extremities, antibiotics started. Last physician note was ER Visit Note dated 04/06/2025 at 10:05 am. As of 04/10/2025 at 10:30 am, no H&P or physician progress notes were found in patient’s record. Per interview with staff #B on 04/10/2025 at 3:35 pm, patient has left the facility. 3) Record review of Face Sheet, Patient Progress Notes (nursing) dated 04/10/2025, and ER Visit Note dated 04/05/2025 reflected patient #8 (current patient), a 54 year-old female with history of lung cancer. Patient records reflected admission to medical inpatient from emergency department on 04/05/2025 at 11:26 pm for pneumonia. Last physician note was from ER Visit Note on 04/05/2025 at 11:37 pm. As of 04/10/2025 at 10:50 am, no H&P or physician progress notes were found in patient’s record. 4) Record review of Face Sheet, Patient Progress Notes (nursing) dated 04/10/2025, United Regional Hospitalist Discharge Summary dated 03/31/2025 and ER Visit Note dated 04/01/2025 reflected patient #27 (discharged patient), a 70 year-old male with history of chronic heart failure, urinary tract infection, paroxysmal atrial fibrillation, and COPD. Patient records reflected admission from outside facility to swing bed on 03/31/2025 at 2:07 pm for congestive heart failure exacerbation. Last physician note was ER Visit Note dated 04/01/2025 at 6:09 pm. As of 04/10/2025 at 11:57 am, no H&P or physician progress notes were found in patient’s record. Patient was discharged on 04/07/2025 at 11:55 am. Per interview with staff #B, staff #T saw patient on 04/01/2025 at 6:09 pm, which is greater than 24 hours after admission. The H&P provided was started but not completed (per interview with staff #B) and was signed on 04/10/2025 at 3:30 pm by staff #T. Review of Policy and Procedure titled “History and Physical”, Reference Number: 6129, dated April 2025 reflected the Outcome Standard to provide “A guideline to ensure the compliance of History and Physicals being on the medical record within 24 hours and/or prior to operative and other invasive procedures.” Record review of the the Hospital’s Medical Bylaws, Article III 3.1 noted the Medical Staff Membership requirement to abide by “ ...any department rules, policies and procedures ...” In an interview on 04/10/2025 at 10:55 am, Staff #B confirmed the hospital expectation that patients were to be physician evaluated for a history and physical examination within 24 hours of admission and seen daily during their inpatient hospitalization. The documented admission history and physical examination (H&P) was to be in the patients’ medical chart within 24 hours.”