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Based on record review and interview the facility failed to provide care in a safe setting for 16 of 16 (Patients #1, #2, #3, #4, #5, #6, #8, #11, #12, #13, #14, #15, #16, #17, #18, and #19) patients in that the facility failed to implement and train staff on the temporary emergency evacuation action plan prior to shutting down all elevators in the facility on 07/17/25.

Cross refer: A144

Based on record review and interview the facility failed to provide care in a safe setting for 16 of 16 (Patients #1, #2, #3, #4, #5, #6, #8, #11, #12, #13, #14, #15, #16, #17, #18, and #19) patients in that the facility failed to implement and train staff on the temporary emergency evacuation action plan prior to shutting down all elevators in the facility on 07/17/25.
Findings included:


Observations on 07/30/25 at 10:50 AM reflected ....The facility consisted of three floors and included a lower floor, a first-floor rehabilitation and transition care unit, and second floor behavioral health unit. The facility had two elevators that serviced the patient care areas. Both elevators were nonfunctional as observed during a previous visit on 07/03/25. On 07/17/25 both elevators for the patient care areas were taken out of service per Personnel #5.

The Alternative Life Safety Measure document reflected ..."Date Deficiency Identified: 07/03/25 ... Deficiency Description ...facility elev.(elevator) Currently out of service ...Corrective Action Plan ...Estimated Date of Repair/Resolution" 6/8 weeks ...As part of our ongoing commitment to safety and facility improvements, the elevator in question Has already been approved for full modernization. The project is currently in progress and is expected to take approximately 6 to 10 weeks ..."

The Temporary Emergency Evacuation Action Plan (no date) reflected ..."2. Alternative Evacuation Methods: Emergency Evacuation Sleds (for patients and staff needing assistance) Bed Mattress Drag Method (last resort in life-threatening situations) ...3. Staff Education and Training Plan: A. Initial Training: -All clinical and support staff will undergo mandatory in-service training on: -Location and proper use of evacuation sleds-Mattress evacuation technique (drag and carry methods) ..."

During a tour of the facility on 07/30/25 at 10:50 AM Personnel #6 and Personnel #7 were asked if they had received training on how to evacuate a non-ambulatory patient in the case of an emergency.? Personnel #6 and Personnel #7 both stated they had "not received any training since the elevators had been taken out of service."
During an interview on 07/30/25 at 11:05 AM Personnel #1 stated all current patients on the second floor were ambulatory. Personnel #1 stated "the facility developed a plan to evacuate a non-ambulatory method using a mattress if needed prior to the evacuation sleds that were ordered being delivered." When asked if the staff had received training on the mattress method, Personnel #1 stated "not yet."

During an interview on 07/30/25 at 11:53 AM Personnel #5 stated" the facility had ordered a sled for evacuation" but it had not arrived at the facility yet. Personnel #5 stated the facility had not provided staff training on how to evacuate a patient via the mattress method.

During an interview on 07/31/25 at 10:14 AM Personnel #5 stated all elevators were out of service on 06/11/25, 06/14/25, 06/15/25, 06/16/25, 06/17/25, and 06/18/25. The facility made the decision to "take all elevators out of service on 07/17/25 after the Action Plan had been developed."

During a telephone interview on 07/30/25 at 05:28 PM Personnel #8 stated they "had not received training on how to evacuate a non-ambulatory patient in case of an emergency."

Based on record review and interview the facility failed to provide services under the orders of a qualified and licensed practitioner for 1of 1 (Patient #1) patients in that a respiratory therapist applied oxygen to Patient #1 without a qualified practitioners order twice within approximately five hours the night of 07/12/2025 and 07/13/2025



Findings included:



Patient #1 was 15-year-old with a history of obstructive sleep apnea. The record titled Edit Oxygen Delivery dated 07/12/25 at 11:48 PM reflected ..."RN (Registered Nurse) called for RT [Respiratory Therapy] for lower O2 sats [oxygen saturation]. Patient 90-91% when RT arrived. Placed on 1 L (liter) O2 patient came up to 99"



Patient #1's record titled Edit Oxygen Delivery dated 07/13/25 at 05:12 AM reflected ..."RT came to reassess patient ...Liter flow turned up to 3L ..."



During an interview on 07/30/25 at 11:43 AM Personnel #4 stated the hospital policy allowed the Respiratory Therapist to stabilize the patient and then call for an order for oxygen. Personnel #4 stated he did not see an order for oxygen in the record until 07/14/25, approximately 24 hours later.



The policy titled Oxygen Therapy dated 12/02/2024 reflected ..."Respiratory care staff and/or qualified nursing staff may set up and discontinue oxygen therapy as per physician or NP (Nurse Practitioner) order. In the event, when a physician is not at bedside, staff may provide sufficient FiO2 to resolve cyanosis and immediately notify the physician or NP of the patient's condition and obtain further orders ..."