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Based on Life Safety Code survey, Margaret Mary Community Hospital, Inc. was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and NFPA 101, LSC, Chapter 18, New Health Care Occupancies for the 2009 addition.

The Margaret Mary Community Hospital was constructed at five different times. The original building was built in 1932 and is a four story, partially sprinklered building (the first, second and third floors are not sprinklered) of Type I (332) construction with a basement. In 1971, a two story addition was constructed to the east of the original building and is also of Type I (332) construction with a basement and fully sprinklered. In 1991, a one story addition, labeled as the "Same Day Surgery Wing," was constructed to the north of the original building and is also Type I (332) construction and fully sprinklered. In 2001, a one story addition, labeled as the "Radiology and Laboratory," was constructed to the south of the original building and is also Type I (332) construction and fully sprinklered. In 2009, a one story addition, labeled as "Emergency Room," was constructed to the south of the 1971 emergency room and is also Type I (332) construction and fully sprinklered. Because the original building and the 1971, 1991, and 2001 additions are the same type of construction, these portions of the facility were surveyed with NFPA 101, LSC, Chapter 19, Existing Health Care Occupancies. The 2009 addition was surveyed with NFPA 101, LSC, Chapter 18, New Health Care Occupancies. The facility had a fire alarm system with smoke detection in the corridors, spaces open to the corridors, and all patient sleeping rooms in the 1971 and 2009 additions. The facility has a capacity of 25 and had a census of 25 at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 2 of 8 open use areas in the 1932 building were separated from the corridor or met an Exception (see K 17), failed to ensure 4 of 4 exit discharge paths in the 1932 building were provided with emergency powered illumination (see K 046), and failed to ensure 1 of 3 automatic sprinkler piping systems was inspected every five years (see K 062).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged, and maintained to ensure the provision of quality health care in a safe environment.

Based on document review and interview, the facility failed to document that 13 of 21 pieces of patient care equipment were maintained in a safe operating condition.

Findings:

1. On 1-5-09 facility staff was requested to provide documentation of preventive maintenance for 21 pieces of patient care equipment and no documentation was provided, prior to exit, for the following pieces:

Olympic Mini Pasturematic - MMCH 6631
Elgin Exercise Machine - MMCH 6590
Shoulder Wheel
Nesar Shoulder Slide - MMCH 6592
Apollo 5 Exercise Machine
Lift Station - MMCH 6595
Parallel Bars - Model 14150
EKG Machine
Hydrocollator
Linear Accelerator
Ventilator
Polysomnography Machine
Adjustable Overhead Operating Room Lights

Based on observation, record review, and interview, the facility failed to ensure 2 of 8 open use areas in the 1932 building were separated from the corridor or met an Exception, failed to ensure 4 of 4 exit discharge paths in the 1932 building were provided with emergency powered illumination, and failed to ensure 1 of 3 automatic sprinkler piping systems was inspected every five years.

Findings:

1. Observations on 01/07/10 during a tour of the facility from 9:20 a.m. to 1:55 p.m. indicated the 1932 building second floor human resources office had a four foot by four foot sliding glass window, which when closed, left a one inch gap between the human resources office and the corridor, and the basement vending machine room, which lacked a door, was open to the corridor.
2. Exception # 1, requirement (c) of the Life Safety Code, Chapter 19.3.6.1 was not met as follows: the open areas were not protected by an automatic smoke detection system or arranged to allow direct supervision by facility staff from a continuously staffed area such as a nurses' station.
3. This was verified by the director of plant operations at the time of observations.
4. Observations on 01/06/09 during a tour of the facility from 9:40 a.m. to 2:20 p.m. indicated building 1 East Wing exit, the two 1 West Wing exits, and the 1 North Wing Exit lacked outside emergency lighting outside each exit door.
5. This was verified by the director of plant operations at the time of observations.
6. Review of Sprinkler System Inspection and Testing Reports 01/06/10 at 9:40 a.m. indicated the Sprinkler System Inspection and Testing Report dated 12/01/09, 08/24/09, 09/04/09, 10/20/08, and 07/28/08 lacked documentation that an internal inspection of the sprinkler system pipes for the 1932 building dry sprinkler system riser was conducted.
7. In interview with the director of plant operations on 01/07/10 at 10:30 a.m., it was indicated a 01/07/10 phone conversation with the inspection company at 9:00 a.m. verified an internal pipe inspection of the 1932 building dry sprinkler riser had never been conducted.

Based on document review and interview, the facility failed to follow its Post Partum Care policy during the recovery period for 2 of 2 obstetrical medical records (MR) reviewed.

Findings include:

1. Review of policy/procedure Post Partum Care indicated the following:
"1. During immediate recovery period, blood pressure and heart rate must be taken every 15-20 minutes times four. When these vitals are taken, a fundal and episiotomy check must also be done and documented."
This policy/procedure was last reviewed/revised on 02-16-09.

2. Review of patient #11's MR indicated that she delivered a baby on 10-05-09 at 2042 hours. Vital signs and fundal and episiotomy checks were documented as follows:
10-05-09 at 2057 blood pressure(NIBP): 118/64, heart rate (HR) 75
10-05-09 at 2058 Fundus firm at umbilicus and small bleeding
10-05-09 at 2106 NIBP: 109/68, HR 72
10-05-09 at 2121 NIBP: 111/60, HR 81
10-05-09 at 2130 Fundus firm at umbilicus; moderate bleeding.
10-05-09 at 2146 NIBP: 122/56, HR 68.

3. Review of patient #13's MR indicated that she delivered a baby on 11-26-09 at 1457 hours. Vital signs and fundal and episiotomy checks were documented as follows:
11-26-09 at 1459 NIBP: 113/79, HR 112
11-26-09 at 1508 NIBP: 106/71, HR 117
11-26-09 at 1511 Fundus firm and midline at umbilicus.
11-26-09 at 1523 NIBP: 109/67, HR 104
11-26-09 at 1538 NIBP: 118/74, HR 112
11-26-09 at 1550 Fundus firm at U/1; bleeding small to moderate.

4. Patient #11 and 13's MR lacked documentation that fundal checks were done times 4 every 15-20 minutes.

5. On 01-06-10 at 1410 hours staff #41 confirmed the fundal checks were not documented.

Based on document review and interview, the facility failed to ensure that the patient care policies were reviewed at least annually by a group of professional personnel that included one member who is not a member of the CAH staff.

Findings include:

1. Review of the Patient Care Policy Manual indicated lack of documentation that a physician non medical staff member reviewed the policy manual on an annual basis.

2. On 01-06-10 at approximately 1340 hours, staff #41 confirmed that the Patient Care Policy Manual is reviewed annually by a facility physician committee, that committee does not have a physician who is not a member of the CAH Medical Staff and the policy manual is not reviewed by physician who is not a member of the CAH Medical Staff annually.

Based on interview, it could not be determined that the facility ensured patients and staff were not exposed to radiation hazards due to lack of policies and procedures describing the proper use, according to manufacturer guidelines, of the various pieces of radiological equipment.

Findings:

1. On 1-6-10, facility staff was requested to provide policies describing the operation of radiological pieces of equipment according to manufacturer guidelines, including but not limited to, fluoroscopy machine, MRI machine, CT Scanner, nuclear medicine gamma camera, mammography machine and ultrasound machine. No documentation was provided prior to exit.

Based on document review and interview, the facility failed to ensure that a doctor of medicine or osteopathy had examined the patient immediately before surgery to evaluate the risk of the procedure to be performed for 1 of 2 surgical medical records (MR) reviewed.

Findings include:

1. Review of patient #5's MR indicated the patient had surgery on 11-16-09. Review of patient #5's MR indicated that a CRNA documented the patient's ASA risk category as a P2. Patient #5's MR lacked documentation that a doctor of medicine or osteopathy had evaluated the risk of the procedure to be performed.

2. On 01-06-10 at 1315 hours, staff #41 confirmed that a CRNA documented the patient's ASA risk category.

Based on document review and interview, the facility did not have an effective quality assurance program because there was no documentation of corrective action in 2 instances.

Findings:

1. Review of a document entitled Ongoing Professional Practice Evaluation for physician MD#10, the Peer Review indicated the physician had appropriate VTE prophylaxis ordered in 1 of 3 (33.3%) cases. The Benchmark or Goal was 100%.

2. Review of a document entitled Ongoing Professional Practice Evaluation for physician MD#11, the Peer Review indicated the physician had appropriate VTE prophylaxis ordered in 2 of 4 (50%) cases. The Benchmark or Goal was 100%.

3. Review of the Governing Board's Joint Conference Committee minutes for year 2009, indicated this information was presented to the committee. However, there was no documentation of any corrective action taken by the committee.

4. Review of the Governing Board minutes for year 2009, indicated this information was presented to the committee. However, there was no documentation of any corrective action taken by the committee.

5. On 1-6-10, employee #A4 was requested to provide documentation of corrective action taken by the committee or board and none was provided prior to exit.

Based on document review and interview, the hospital failed to comply with their contract to notify an organ procurement organization of all deaths.
Findings:
1. Review of the contract between the hospital and the facility's Organ Procurement Organization (OPO), indicated the hospital shall immediately report all deaths to a one number system as directed by CMS COP 42 CFR Part 482.45 (1). To notify the OPO or a third party designated by the OPO (Statline) as agreed to by ILETTB and the hospital's designated OPO and tissue bank.
2. Review of a report entitled Margaret Mary Community Hospital Donation 2009 Statistics and Benchmarks, indicated that for the period January 1, 2009 through December 31, 2009, there were 62 hospital deaths and 59 were reported to the OPO.
3. On 1-5-10 at 2:15 pm, employee A2 was requested to present any other documentation on the above subject and none was provided prior to exit.