HospitalInspections.org

Based on record review and interview, the hospital failed to meet the Condition of Participation for Governing Body. The hospital's governing body failed to ensure services within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This deficient practice was evidenced by:

The hospital's governing body failing to effectively carry out the functions of the hospital, as were held out as being available to the public and failing to provide the funding needed by the hospital in order to purchase supplies and maintain staff for services such as surgery, ultrasound, nuclear medicine, cardiac cath lab and dialysis. (See Findings at A-0115, 0528, 0576, 0940, 1025, 1100)

As a result of this noncompliance, on 12/08/2023 at 11:00 a.m., S1CEO was informed of the Immediate Jeopardy situation that existed. Patients were denied services and/or delayed treatment due to inadequate staffing and/or supplies. Patients were refused admittance to this hospital and inpatients/ED patients were transferred out to other hospitals due to these lack of services, which were held out to the public as being available.

On 12/11/2023 at 10:00 a.m., the hospital provided a plan of removal for the Immediate Jeopardy situation. This plan included:
- Shift to shift monitoring of staffing levels in all departments. The house supervisor will notify the senior leader responsible of variance in expected staffing to determine the delivery of safe care.
- Senior leadership team will monitor supply levels daily to assure they can meet the needs of the patients.
- Daily review of ED transfer logs will be conducted to assure appropriate patient disposition at time of service.
- An inventory of critical/needed supplies will be conducted daily and discussed with the Executive Vice President of Materials Management/designee to assure adequate supplies are sourced and onsite.
- Daily report to corporate leadership to assure funding is available for all staffing and supply needs of the organization.
- All reported concerns from providers and staff both verbal, and via online incident reporting system will be reviewed daily by senior leadership team until all issues are resolved.
- The weekly OR schedule will be monitored to assure the supplies are on hand for upcoming cases.

On 12/14/2023 at 9:37 p.m., the Immediate Situation was lifted and the deficiencies remain at Condition levels.

Based on observation and interview, the hospital failed to ensure that supplies and services provided or performed under contract and vendor agreements were provided in an effective manner as evidenced by failure of the governing body to pay vendors and contracts for staffing, specialized beds and supplies. As a result, many vendors placed provision of supplies and services on credit holds and failed to ship supplies.
Findings:

Review of the 2023 Governing Body meeting minutes revealed the following::
- In January 2023, 112 transfers were denied due to staffing; there were 37 lost inpatient surgeries due to transfer denials (staffing); several inpatient vascular cases were canceled due to accounts payable issues
- In April 2023, there were transfer denials due to staffing and equipment issues; the C-arm was down causing a decrease in orthopedic surgeries; outpatient cath procedures were down due to the loss of a cardiovascular physician; there were decreases from the prior month in surgeries, cath and endoscopy procedures.

Review of a letter dated 04/11/23 to the hospital's Governing Body from the MEC (Medical Executive Committee), signed by 10 physicians (including S4MD (Chief of Radiology); S5MD (Chief of Cardiology); S7MD (Chief Medical Officer) and S7MD (Chief of Surgery) revealed it included the following:
They expressed "deep concern regarding current issues that we strongly feel are hindering our ability to render safe and effective care to patients".
Multiple departments have reported imminent threats from vendors to service lines and/or supply chains critical to providing quality patient care.

The letter included specific examples which were:
Pathology department - The blood center informed the hospital that they may no longer be able to provide blood products to the facility.
Nephrology department - The dialysis provider informed the hospital that they may have to pull hemodialysis services from the facility.
Cardiovascular Surgery department - "MANY" vendors informed that they were considering no longer supplying artificial valves, endografts and other cardiovascular supplies.
Radiology department - There were limitations in ultrasound , computed tomography, and interventional radiology procedures due to lack of critical supplies and manpower.
Each cited long overdue payments as a reason for their considerations.

"As a result of non-payment, other departments have already had to limit procedures or deal with limited available operating room times due to lack of supplies. Cardiology has suffered due to limited availability of wires for heart cath procedures. Radiology cited similar concerns regarding lack of availability of suction canisters. For Pulmonology/Critical Care the concern has been ventilators and related supplies. Cardiovascular surgery has been limited by availability of oxygenators and pumps for the heart-lung machines.
In addition, specialists from Pulmonology, Cardiology, and Cardiovascular surgery outpatient clinics all report patients expressing concern directly to them that they were fearful or concerned about receiving care at the hospital citing safety concerns due to lack of supplies. This is a strong indication that concerns have also become apparent to the community at large."

"Other serious concerns: several specialists have reported not receiving call pay for some time. There has been a departure of staff citing uncertainty regarding the future direction of the company - this included the ER medical director and a long-time hospitalist. Outpatient primary care providers have transitioned to another clinic, which poses a threat to the outpatient referral base."

There was concern that these and other issues have resulted in a decline in the relationship between the hospital and the community, and a growing distrust from local vendors and the patient population. They felt that the "root of many of these issues is the current corporate practice of not paying vendors in a timely manner".

Review of MEC meetings from May to November, 2023 confirmed that the above concerns continued to be a problem, including professional staff and contracted service withdrawals including physicians, telepsych services, the Long Term Acute Care provider, and the dialysis provider. Several major vendors stopped servicing the hospital, affecting Cardiology and Surgery services.


1. On 12/07/2023 at 2:00 p.m., during the entrance conference with S1CEO and S2CNO, S1CEO reported that the hospital has been having issues for several months with staffing and obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients.

S1CEO stated that the hospital is an accredited chest pain hospital but the hospital will be on STEMI diversion on this day from 5:00 p.m. until 7:00 a.m. the next morning due to staffing and supply issues in the heart cath lab. S1CEO confirmed there was a large sign on the front of the hospital indicating that this hospital was an Accredited Chest Pain Hospital.

S2CNO stated that the hospital went for several weeks recently without PICC lines, due to credit hold on vendor, and central lines were used instead of PICC lines at that time. S2CNO stated that the central lines increased the risk of infection for these patients.

S2CNO further revealed that the hospital's dialysis supplies had been depleted, but just got a shipment in today. S2CNO stated that the hospital was on credit hold with their dialysis supplier and they had stopped sending supplies, so they had been borrowing from other hospitals. S2CNO further stated that the hospital had not been accepting dialysis patient transfers due to having no supplies and was on dialysis diversion for a few days.

2. On 12/07/2023 at 3:30 p.m., when S3Director of Radiology was asked about issues with supplies, S3 stated that the department is out of IVC filters, clips for mammograms and only has one CT biopsy kit available. S3 stated that mammogram is out of tissue markers and those patients are being referred to another hospital for that service due to lack of supplies.

S3 further stated that the specialized pulse oximeter used for sedated patients in the MRI is broken, but is unable to be fixed due to credit hold with the repair company. When asked what is done for patients who have orders for an MRI with sedation, S3 stated they would have to be transferred to another hospital because of the lack of a working pulse oximeter specific for MRI machines.

S3 revealed that the radiology department (nuclear medicine) required a quarterly survey by a physicist company on 11/17/2023 to ensure proper dosing, but it was not performed due to non-payment. As a result, the hospital had to stop performing nuclear medicine procedures until the vendor was paid on 11/30/2023. S3 stated that patients who required nuclear medicine testing during that time frame were referred to other hospitals.

S3 also stated that the MRI machine door was broken from 10/16/2023 until 11/02/2023. He stated the door could not be repaired due to vendor hold issues. When asked what happened to patients who had orders for MRI during this time frame, S3 stated they would be transferred to other hospitals for that service.

S3 further stated that the nuclear medicine department required a quarterly survey by a physicist company on 11/17/2023 to ensure proper dosing, but it was not performed due to non-payment. As a result, the hospital had to stop performing nuclear medicine procedures until the vendor was paid on 11/30/2023. S3 stated that patients who required nuclear medicine testing during that time frame were referred to other hospitals.

3. On 12/08/2023 at 12:45 p.m., an interview was conducted with S4MD (Medical Director of Radiology). S4MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S4MD stated they have ran out of supplies for Special Procedures, such as IVC filters, breast biopsy needles, central lines, dialysis catheters and PICC lines due to credit holds with vendors. He stated there would be stints where the vendors would be paid and supplies would arrive and then the supplies would diminish again.

S4MD revealed that two weeks ago, the hospital was unable to utilize nuclear medicine services due to the hospital failing to pay for the state required physicist survey. S4MD stated that patients could not have bone scans and heart or abdomen scans during that time.

S4MD revealed that approximately one month ago, the MRI machine broke down for three weeks and it was unable to be repaired during that time due to credit hold with vendor. S4MD also revealed that two weeks ago, the hospital was unable to utilize nuclear medicine services due to the hospital not paying for the physicist survey. S4MD stated that patients could not have bone scans and heart or abdomen scans during that time.

S4MD stated that there was no 24/7 ultrasound coverage at the hospital and the staffing company that supplies the ultrasound techs is pulling them out soon due to nonpayment. S4MD compared it to "third world medicine" at the hospital. He further stated that patient care is in jeopardy when a patient needs a filter or a catheter and there are no supplies or staff to perform it.

4. On 12/11/23 at 1:00pm, an interview with S8RN/Director of Surgery revealed that the hospital was unable to provide surgeries for urology and orthopedics due to issues with vendor holds on supplies such as: drapes for robotic surgeries; open ended catheters, loops for TURP (transurethral resection of prostate) procedures, stents, Floseal for urology procedures; marker spheres, Surgiflo and bone saws for orthopedic surgeries. S8RN confirmed that the supplies needed to conduct theses procedures were unavailable and that some surgeries had been cancelled due to the lack of supplies.

S8RN further revealed the vendor for the laparoscopes is holding scopes sent out for repair due to payment issues and they are currently down to three scopes - they normally have 10 scopes available.

5. On 12/12/23 at 1:30pm, an interview with S7MD (Chief of Surgery) confirmed there were several vendors that have been on hold beyond 30 days, and surgeries have been cancelled or delayed as a result. S7MD stated the surgical vendors were all placed on hold at about the same time in August or September 2023.

S7MD confirmed that surgical services have been cancelled due to lack of robotic drapes and supplies for spines, knees and shoulders. They are doing emergency only now (hips and femurs), and stated the situation is "just tragic."
S7MD stated the only urologist is leaving after next month because he has had to cancel half of his procedures due to supplies not available for TURPs and lithotripsies. Endoscopy and gastroenterology procedures are affected due to supply issues and inability to treat bleeds. General surgeries are affected due to supply issues with mesh and drapes. S7MD further stated the hospital no longer has an ENT or gynecologist. S7MD confirmed he has not provided on-call services for the last 10 days because he has not been paid since 10/31/23.

Review of the hospital's policy for Scope of Services - OR (approved 05/05/22) failed to reveal the types of surgical services provided by the hospital.

6. On 12/07/2023 at 4:30 p.m., interview with S2CNO confirmed that the hospital was on credit hold with the vendor that supplies specialized beds, such as air loss beds and bariatric beds.

On 12/14/2023 at 9:10 a.m., observation of Patient #7 revealed that the patient was in an ICU regular bed with a standard waffle overlay. At that time, interview with the patient's nurse revealed that staff had to remove the patient from his speialized air loss bed last night because the vendor was going to pick up the bed.

7. On 12/08/23 9:15am, an interview with S9Director of Dietary Services revealed two of three dietary department vendors (produce and milk) are on shipping holds due to payment issues.

8. Review of the log for transfers out of the ED dated December 1-5, 2023 10 patients were transferred to other facilities. Further review revealed 3 of the 10 transfers were for dialysis services, which was a service that this hospital offered but did not have supplies to provide.

Review of the log for transfer denials for December 1-5, 2023 revealed 4 denials for dialysis patients due to lack of dialysis supplies. Dialysis is a service offered by this hospital.

9. Review of the log for trasfer denials for December 1-5, 2023 revealed 2 patient denials due to lack of bariatric beds.



20310

Based on record review and interview, the hospital failed to meet the Condition of Participation for Patient Rights. Patients were delayed treatment due to inadequate staffing in the heart cath lab and lack of supplies in surgery. As a result, 2 patients were transferred to other hospitals for these services. (See findings at A-0144)

Based on record review and interview, the hospital failed to ensure that patients recieved care in a safe setting as evidenced by failing to provide needed supplies and staffing for 2 patients who required procedures. As a result, these 2 patients had to be transferred to another hospital for the required procedures, which delayed their treatment (Patient #4, Patient #6).
Findings:

1. Review of the medical record for Patient #4 revealed an admission date of 12/05/2023. The patient was taken to surgery on 12/05/2023 to perform aortogram with runoff and stenting of right external iliac artery.

Further review of the record revealed documentation dated 12/08/2023 that the patient reported chest pain last night. An EKG was performed which showed ST elevation. Documentation revealed the heart "cath lab was unavailable at this facility therefore we had to emergently transfer patient" to Hospital A for emergent left heart cath. Prior to transfer, the patient was in A-Fib with RVR. Documentation revealed the heart cath was performed and it showed a 90% ostial in-stent restenosis followed by an 80% proximal in-stent restenosis. The patient was then transferred back to the original hospital.

On 12/08/2023 at 9:30 a.m., an interview was held with S5MD (Chief of Cardiology/Director of Cath Lab). S5MD stated that Patient #4 was his patient and had to be transferred last night to Hospital A for a heart cath. S5MD stated that the cath lab at this hospital was closed due to having no staff available. S5MD revealed that this transfer was not safe for his patient and he was very stressed over this situation.

S5MD further stated that staffing issues started about one year ago and have gotten progressively worse in the last couple of months. S5MD stated there is no weekend and evening coverage for nuclear medicine and ultrasound staffing is not consistently covered. S5MD further stated that he has not gotten his on-call pay for the past three months call schedule and stated other physicians have not been paid either.

S5MD further revealed that he frequently transfers patients to out of state hospitals due to lack of beds and staffing at this hospital.

2. Review of the medical record for Patient #6 revealed the patient presented to the ED on 11/30/2023 with complaints of abdominal pain. The initial exam suggested possible holangiocarcinoma.

Review of the patient's medical record revealed documentation dated 11/30/2023 that the patient was sent out for an ERCP due to "unable to proceed with ERCP at this facility secondary to supply shortage".

On 12/12/2023 at 4:10 p.m., interview with S2CNO confirmed that the patient was transferred out to another facility due to lack of supplies to perform the ERCP.

Based on record review and interview, the hospital failed to measure, analyze and track all patient adverse events, staffing and supply issues through the quality assessment and improvement program, as evidenced by failure of the hospital to address incidents involving patient transfers and denials, and departmental issues with staffing and supplies.
Findings:

1. Review of the medical record for Patient #4 revealed documentation dated 12/08/2023 that the patient reported chest pain last night. An EKG was performed which showed ST elevation. Documentation revealed the heart "cath lab was unavailable at this facility therefore we had to emergently transfer patient" to Hospital A for emergent left heart cath. Prior to transfer, the patient was in A-Fib with RVR. Documentation revealed the heart cath was performed and it showed a 90% ostial in-stent restenosis followed by an 80% proximal in-stent restenosis. The patient was then transferred back to the original hospital.

On 12/08/2023 at 9:30 a.m., an interview was held with S5MD (Chief of Cardiology/Director of Cath Lab). S5MD stated that Patient #4 was his patient and had to be transferred last night to Hospital A for a heart cath. S5MD stated that the cath lab at this hospital was closed due to having no staff available. S5MD revealed that this transfer was not safe for his patient and he was very stressed over this situation.

2. Review of the medical record for Patient #6 revealed the patient presented to the ED on 11/30/2023 with complaints of abdominal pain. The initial exam suggested possible holangiocarcinoma.

Review of the patient's medical record revealed documentation dated 11/30/2023 that the patient was sent out for an ERCP due to "unable to proceed with ERCP at this facility secondary to supply shortage".

On 12/12/2023 at 4:10 p.m., interview with S2CNO confirmed that the patient was transferred out to another facility due to lack of supplies to perform the ERCP.

3. Review of the log for transfers out of the ED dated December 1-5, 2023 revealed 10 patients were transferred to other facilities. Further review revealed 3 of the 10 transfers were for dialysis services, which was a service that this hospital offered but did not have supplies to provide.

Review of the log for transfer denials for December 1-5, 2023 revealed 4 denials for dialysis patients due to lack of dialysis supplies. Dialysis is a service offered by this hospital.

Review of the log for transfer denials for December 1-5, 2023 revealed 2 patient denials due to lack of bariatric beds.

Review of the hospital's QAPI documentation for 2023 revealed no evidence that patient transfers and denials had been formally measured, analyzed, and/or tracked. Further review revealed no documented evidence that the departmental data included issues related to staffing and supply shortages.

On 12/08/2023 at 10:35 a.m., interview with S10Director of QA revealed that she had no knowledge of any adverse patient events recently. She further stated that the last full QA report completed was for the 3rd quarter of 2023 and she had no QA data to report since that time related to patient adverse events. When S10Director of QA was asked is she was aware of the above patient transferred to another hospital for a cath lab procedure which delayed treatment, she stated no.

Further interview with S10Director of QA on 12/13/2023 at 3:45 p.m. revealed that there was no departmental tracking and reporting of staffing and supply issues within the QAPI reports.



20310

Based on record review and interview, the hospital failed to meet the Condition of Participation for Radiology. The hospital failed to maintain, or have available, diagnostic radiological services such as ultrasound and heart cath lab. As a result, patients were denied services and/or delayed treatment due to inadequate staffing in these departments and lack of supplies to perform needed procedures. (See findings at A-0529)

Based on observation, record review and interview, the hospital failed to maintain, or have available, radiologic services according to the needs of the patients as evidenced by failing to ensure adequate supplies and/or staff coverage for all radiological services held out to the public as provided by the hospital.
Findings:

On 12/07/2023 at 2:00 p.m., during the entrance conference with S1CEO and S2CNO, S1CEO reported that the hospital has been having issues for several months with staffing and obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients.

S1CEO stated that the hospital is an accredited chest pain hospital but the hospital will be on STEMI diversion on this day from 5:00 p.m. until 7:00 a.m. the next morning due to staffing and supply issues in the heart cath lab. S1CEO confirmed there was a large sign on the front of the hospital indicating that this hospital was an Accredited Chest Pain Hospital.

Due to the staffing issues, S1CEO stated that many outpatient imaging services have been canceled in order to utilize those staff members in the hospital.

S2CNO stated that nuclear medicine services are on a part time basis in the hospital, and there is no on-call staff for nuclear medicine after hours for the current week. S2CNO further stated there will be no ultrasound staff coverage on 12/08/2023 from 1:30 p.m. until 9:00 p.m. and no coverage on 12/09/2023 from 6:00 p.m. until 7:00 a.m. the next morning.

S2CNO further stated that as of 12/15/2023, the staffing company that provides ultrasound staff for the hospital stated they will not be providing any more staff after that date due to non-payment.

On 12/07/2023 at 3:30 p.m., an interview was conducted with S3Director of Radiology. S3 stated that there is a lack of staffing in all radiology departments. S3 revealed that there is no full time staff in ultrasound, but only one contracted staff. The contracted staff works Monday through Thursdays and will work on call at night occasionally. S3 confirmed the lack of ultrasound coverage on 12/08/2023 from 1:30 p.m. until 9:00 p.m. and no coverage on 12/09/2023 from 6:00 p.m. until 7:00 a.m. the next morning.

S3 further stated that there was no nuclear medicine coverage on weekends and there was no nuclear medicine coverage for the current week after the fill-in employee (who works full time in another department) gets off at 12:00 p.m. each day.

When asked about issues with supplies for radiology, S3 stated that the department is out of IVC filters, clips for mammograms and only has one CT biopsy kit available. S3 stated that mammogram is out of tissue markers and those patients are being referred to another hospital for that service due to lack of supplies.

S3 further stated that the specialized pulse oximeter used for sedated patients in the MRI is broken, but is unable to be fixed due to credit hold with the repair company. When asked what is done for patients who have orders for an MRI with sedation, S3 stated they would have to be transferred to another hospital because of the lack of a working pulse oximeter specific for MRI machines.

S3 stated that the radiology department (nuclear medicine) required a quarterly survey by a physicist company on 11/17/2023 to ensure proper dosing, but it was not performed due to non-payment. As a result, the hospital had to stop performing nuclear medicine procedures until the vendor was paid on 11/30/2023. S3 stated that patients who required nuclear medicine testing during that time frame were referred to other hospitals.

S3 also stated that the MRI machine door was broken from 10/16/2023 until 11/02/2023. He stated the door could not be repaired due to vendor hold issues. When asked what happened to patients who had orders for MRI during this time frame, S3 stated they would be transferred to other hospitals for that service.

On 12/08/2023 at 12:45 p.m., an interview was conducted with S4MD (Medical Director of Radiology). S4MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S4MD stated they have ran out of supplies for Special Procedures, such as IVC filters, breast biopsy needles, central lines, dialysis catheters and PICC lines due to credit holds with vendors. He stated there would be stints where the vendors would be paid and supplies would arrive and then the supplies would diminsh again.

S4MD revealed that approximately one month ago, the MRI machine broke down for three weeks and it was unable to be repaired during that time due to credit hold with vendor. S4MD also revealed that two weeks ago, the hospital was unable to utilize nuclear medicine services due to the hospital not paying for the physicist survey. S4MD stated that patients could not have bone scans and heart or abdomen scans during that time.

S4MD stated that there was no 24/7 ultrasound coverage at the hospital and the staffing company that supplies the ultrasound techs is pulling them out soon due to nonpayment. S4MD compared it to "third world medicine" at the hospital. He further stated that patient care is in jeopardy when a patient needs a filter or a catheter and there are no supplies or staff to perform it.

Based on observation, record review and interview, the hospital failed to meet the Condition of Participation for Laboratory. The hospital failed to ensure emergency laboratory services were available to each patient, and that necessary laboratory supplies were maintained to provide adequate laboratory services (See findings at A-0582 and A-0583).

Based on observation, record review and interview with laboratory personnel, the hospital failed to ensure the laboratory supplies necessary were maintained to provide adequate laboratory services.
Findings:

Observation during laboratory tour on December 13, 2023 at 9:30 a.m. revealed the laboratory utilized two Sysmex hematology analyzers in use for patient testing. Direct observation of surveyors identified one bottle remaining of CleanCell reagent required for daily maintenance of Sysmex analyzers.

Interview with S12Hematology Supervisor on December 13, 2023 at 10:00 a.m. confirmed only one CleanCell was remaining. S12 further stated the laboratory had been trying to order more CleanCell solution along with many other necessary supplies, and that the laboratory had borrowed some from a sister facility. The laboratory planned to clean the instrument with a 5% bleach solution in the barcoded CleanCell tube until the manufacturer supply was received by the laboratory.

Interview with S11Director of Laboratory services and S13Pathologist on December 14, 2023 at 11:00 a.m. revealed the laboratory has been unable to obtain necessary supplies for numerous laboratory services for nearly six months. When the laboratory cannot obtain the supplies necessary for patient testing due to stock and payment issues, the laboratory contacts other third party vendors or borrows from neighboring facilities. S11 and S13 stated the laboratory notifies administration and corporate in Dallas when there is a critical need for laboratory supplies but the payment issues are not always resolved, resulting in the laboratory being unable to perform testing required or referencing testing to another laboratory, delaying results.

Review of laboratory records from September 2023 - December 2023 revealed the following tests in which the laboratory was unable to obtain the supplies necessary for testing: culture media (all microbiology cultures resulting in send out for identification and sensitivity), Cepheid PCR reagents (Streptococcal-A A, Methicillin-resistant Staphylococcus aureus, COVID, COVID/Flu/respiratory syncytial virus combination), Procalicitonin, Biomerieux organism ID panels, Verigene blood culture panels, Iron, Cortisol, Lipase, Abbott I-Stat cartridges, ACT, blood culture bottles, Radiometer, Sysmex Flourocell, Hemoglobin A1C, urine drug screen reagents, Urinalysis strips and all reagents, Mueller Hinton media, halogen lamps for chemistry instruments, Immucor blood bank quality control.

Further record review of quality control and quality assessment records revealed the laboratory utilized expired quality control material from October 13, 2023 - October 25, 2023 due to a credit hold with the Manufacturer A. The laboratory notified administration and corporate of the critical need and inability to obtain the quality control reagents from the manufacturer prior to their expiration.

Based on interview, the hospital failed to ensure emergency laboratory services were available to each patient, should they require these services, 24 hours a day, 7 days a week. This deficient practice was evidenced by the laboratory failing to have the ability to provide for replacement blood products when their current stock is depleted.
Findings:

Interview on 12/11/2023 at 4:00 p.m. with S11Director Laboratory stated for regular use, our blood supply would last approximately four days. S11 stated they usually order blood every other day and after their delivery on 12/10/2023, the lab was placed on COD (Cash on Delivery) for all blood products. S11 continued to state that they have no current plan or method for paying their supplier's COD.

On 12/11/2023 at 4:20 p.m., interview with S1CEO revealed the hospital had no ability to pay the COD required for blood products.

On 12/12/2023 at 12:35 p.m., interview with S11Director Laboratory revealed the COD was still required by their supplier and the hospital has no ability to pay COD.

On 12/12/2023 at 1:56 p.m., interview with S1CEO revealed the hospital's blood supplier still required COD and they currently have no ability to pay COD for blood products.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Surgical Services. The hospital failed to maintain, or have available, supplies for surgical services such as Spine/Orthopedics, Urology, and General. As a result, patient procedures were cancelled or delayed due to lack of supplies to perform needed procedures. (See findings at A-0941).

Based on observation, record review and interview, the surgical services provided were not appropriate to the scope of services offered as evidenced by failing to maintain supplies necessary for providing the surgical services offered.
Findings:

Review of the hospital's policy for Scope of Services - OR (approved 05/05/22) failed to reveal the types of surgical services provided by the hospital.

On 12/11/23 at 1:00 p.m., an interview with S8RN/Director of Surgery revealed that the hospital surgical procedures included general, cardiovascular, orthopedic/spine, and urology.

S8RN further revealed the OR was unable to provide surgeries for urology and orthopedics due to issues with vendor holds on supplies such as: drapes for robotic surgeries; open ended catheters, loops for TURP procedures, stents, Floseal for urology procedures; marker spheres, Surgiflo and bone saws for orthopedic surgeries. S8RN confirmed that the supplies needed to conduct these procedures were unavailable and that some surgeries had been cancelled due to the lack of supplies.

S8RN further revealed the vendor for the laparoscopes is holding scopes sent out for repair due to payment issues and they are currently down to three scopes - they normally have 10 scopes available.

On 12/12/23 at 1:30 p.m., an interview with S7MD (Chief of Surgery) confirmed there were several vendors that have been on hold beyond 30 days, and surgeries have been cancelled or delayed as a result, with significant decreases since August or September 2023. These vendors include Cook, Medline and Edwards and they were all placed on hold at about the same time.

S7MD further confirmed that surgical services offered by the hospital included ortho/spine, cardiac, vascular and general. Spine and orthopedic procedures have been cancelled due to lack of robotic drapes. S7MD stated the spine surgeons usually have about 40 cases per month and are down to 3-4 procedures per month; no knees and shoulders are being performed due to Stryker vendor on hold. S7MD further stated the OR is doing emergency orthopedics only now (hips and femurs), and stated the situation is "just tragic."

S7MD stated the only urologist is leaving after next month because he has had to cancel half of his procedures due to supplies not being available for TURPs (transurethral resection of prostate) and lithotripsies. Endoscopy and gastroenterology procedures are affected due supply issues and inability to treat bleeds. General surgeries are affected due to supply issues with mesh and drapes. S7MD stated the hospital no longer has an ENT or gynecologist. S7MD confirmed he has not provided on-call services for the last 10 days because he has not been paid since 10/31/23.

Review of the OR cancellation list for the last 30 days revealed 25 surgeries were cancelled or delayed. Seven of the procedures cancelled were related to supplies not available due to vendor holds - 3 robotic inguinal hernia repairs; 1 laparoscopic catheter insertion for peritoneal dialysis; 2 lumbar interbody fusions and 1 shoulder arthroplasty reverse.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Nuclear Medicine. The hospital failed to maintain, or have available, diagnostic nuclear medicine services. As a result, patients were denied services and/or delayed treatment due to inadequate staffing in these departments and lack of supplies to perform needed procedures. (See findings at A-1026)

Based on interview, the hospital failed to maintain, or have available, nuclear medicine services according to the needs of the patients as evidenced by failing to ensure adequate supplies and/or staff coverage for nuclear medicine services held out to the public as provided by the hospital.
Findings:

On 12/07/2023 at 2:00 p.m., during the entrance conference with S1CEO and S2CNO, S1CEO reported that the hospital has been having issues for several months with staffing and obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients.

S2CNO stated that nuclear medicine services are on a part time basis in the hospital, and there is no on-call staff for nuclear medicine after hours for the current week.

On 12/07/2023 at 3:30 p.m., an interview was conducted with S3Director of Radiology. S3 stated that there is a lack of staffing in all radiology departments. S3 stated that there was no nuclear medicine coverage on weekends and there was no nuclear medicine coverage for the current week after the fill-in employee (who works full time in another department) gets off at 12:00 p.m. each day.

S3 further stated that the nuclear medicine department required a quarterly survey by a physicist company on 11/17/2023 to ensure proper dosing, but it was not performed due to non-payment. As a result, the hospital had to stop performing nuclear medicine procedures until the vendor was paid on 11/30/2023. S3 stated that patients who required nuclear medicine testing during that time frame were referred to other hospitals.

On 12/08/2023 at 12:45 p.m., an interview was conducted with S4MD (Medical Director of Radiology). S4MD revealed that two weeks ago, the hospital was unable to utilize nuclear medicine services due to the hospital not paying for the state required physicist survey. S4MD stated that patients could not have bone scans and heart or abdomen scans during that time.

S4MD compared it to "third world medicine" at the hospital. He further stated that patient care is in jeopardy when services such as nuclear medicine is not available for patient diagnosis and treatment.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Emergency Services as evidenced by failing to ensure its integrated services were properly staffed to provide the patients with appropriate diagnostic and care interventions (See findings at A-1103).

Based on administrative interviews, the hospital failed to ensure its integrated services were properly staffed to provide its patients with appropriate diagnostic and care interventions.
Findings:

On 12/07/2023 at 2:00 p.m., during the entrance conference with S1CEO and S2CNO, S1CEO reported that the hospital has been having issues for several months with staffing and obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients.

S1CEO stated that the hospital is an accredited chest pain hospital but the hospital will be on STEMI diversion on this day from 5:00 p.m. until 7:00 a.m. the next morning due to staffing and supply issues in the heart catheter lab.

S2CNO stated that nuclear medicine services are on a part time basis in the hospital, and there is no on-call staff for nuclear medicine after hours for the current week. S1CNO further stated there will be no ultrasound staff coverage on 12/08/2023 from 1:30 p.m. until 9:00 p.m. and no coverage on 12/09/2023 from 6:00 p.m. until 7:00 a.m. the next morning.

S2CNO further stated that as of 12/15/2023, the staffing company that provides ultrasound staff for the hospital stated they will not be providing any more staff after that date due to non-payment.

On 12/07/2023 at 3:30 p.m., an interview was conducted with S3Director of Radiology. S3 stated that there is a lack of staffing in all radiology departments. S3 revealed that there is no full time staff in ultrasound, but only one contracted staff. The contracted staff works Monday through Thursdays and will work on call at night occasionally. S3 confirmed the lack of ultrasound coverage on 12/08/2023 from 1:30 p.m. until 9:00 p.m. and no coverage on 12/09/2023 from 6:00 p.m. until 7:00 a.m. the next morning.

On 12/08/2023 at 12:45 p.m., interview with S4MD revealed that there was no 24/7 ultrasound coverage at the hospital and the staffing company that supplies the ultrasound techs is pulling them out soon due to nonpayment. S4MD compared it to "third world medicine" at the hospital. He further stated that patient care is in jeopardy when a patient needs a filter or a catheter and there are no supplies or staff to perform it. S4MD stated that you cannot run an ED without these diagnostic services.

Review of the transfer log for the ED for December 1-5, 2023 revealed 10 transfers to other facilities. Further review revealed 3 of the 10 transfers were for dialysis services, which was a service that this hospital offered but did not have supplies to provide.




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