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Tag No.: C0200
Based on record review and interview, it was determined that the Critical Access Hospital (CAH) failed to meet the needs of its outpatients by making emergency services available 24-hours a day (cross refer to C 201).
Tag No.: C0201
Based on interviews with staff, and review of facility records, it was determined that the Emergency Room (ER) failed to provided 24 -hour emergency services, by closing the ER for two days.
Findings include:
A news report on 4/29/18 in the local media stated that Alice Peck Day emergency department was shut down for over two days. Review on 5/1/18 of the facility's event description for the ER shutdown revealed the following:
1) "...ER Department was closed from approximately 11 p.m. on 12/2/17 until approximately 5 p.m. on 12/4/17 as the ER did not have access to the CT [Computerized Axial Tomography] equipment and repairs were unable to be completed timely..."
2) On 12/2/18 "11 p.m. Doors to ED [Emergency Departmetn] were posted with signage stating : Diversion: Call 911 or go to [hospital name omitted]"
Interview on 5/1/18 at approximately 11:45 a.m. with Staff A (ER Manager) revealed that the emergency department was closed from 12/2/17 at 11 p.m. until approximately 5 p.m. on 12/4/17 due to the CT scanner being broken and also confirmed that signs were posted on the ambulance door entrance and also the main emergency door entrance instructioning patients to go call 911 or go to (hospital name omitted). Staff A revealed that most of the patient that are treated at the ER are walk-in patients.
Interview on 5/1/18 at 12:00 p.m. with Staff B (ER Nurse) confirmed that the department was fully staffed but the doors were locked and that the signage placed on the doors prevented walk-in patients from entering the ER.
Interview with Staff C (Director of Risk Management) on 5/1/8 at 1:30 p.m. revealed the average daily census for Sundays is 9.2, and Mondays is 11.25. Staff C was also asked how many times was the CT scanner used for the month of December by the ER department and Staff C validated that the unit was used 26 times stating about one patient per day.