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Based on observation, interview and document review the Critical Access Hospital (CAH) failed to ensure they provided laboratory services by agreement or arrangement for medical management of emergency medical conditions. The CAH failed to follow their chest pain policy and procedure for three of three patients (Patients 2, 3, and 5) with cardiac complaints, and two of three patients (Patients 1 and 6) with suicidal thoughts. The CAH has a decreased ability to provide hemodynamic monitoring and a decreased ability to identify patient perfusion problems.

The CAH's failure to ensure to provide emergency services as directed by their policies, procedures, and protocols for medical management of emergency medical conditions has the potential for loss of continuity of care and poor patient outcomes.


Findings Include:

Document review of the Critical Access Hospital (CAH) "Medical Staff Bylaws," dated 04/14/03, showed the CAH was organized for the purpose of providing health care and medical services for inpatients and outpatients and promoting the well-being of the citizens of the town and the surrounding area.

Document review of the CAH policy titled, "Laboratory; Scope of Services," dated 07/2014, showed, The Department of Laboratory Services provides stat and routine clinical laboratory and anatomic pathology services for hospital inpatients and outpatients, clinic and other non-hospital patients, and non-HCH healthcare providers. And also showed, Hours of Operation; Inpatient, Swing Bed, observation, and ER Patients: 24 hours per day, 7 days per week, and 365 days per year and Scope of Services provided; clinical laboratory services, clinical laboratory reference lab services, and anatomical pathology services.

Document review of the CAH Emergency Department Policy and Procedure titled, "Chest Pain" dated 10/2013 showed, staff are to draw lab for a Cardiac Profile which includes the following: Complete Blood Count with differential (CBC) blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia), comprehensive metabolic panel (CMP) is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working), Cardiac Enzymes (measure the levels of enzymes and proteins that are linked with injury of the heart muscle. These include the enzymes creatine phosphokinase (CPK) and creatine kinase (CK), and the proteins troponin I (TnI) and troponin T (TnT), A prothrombin time (PT) is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the international normalized ratio (INR) is calculated from a PT result and is used to monitor how well the blood-thinning medication (anticoagulant) warfarin (Coumadin®) is working to prevent blood clotting (PT/INR), and A partial thromboplastin time (PTT) test is a blood test that helps doctors assess your body's ability to form blood clots.


Review of Patient 2's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 01/03/19 at 11:55 AM with the following complaints: dizziness, clammy, and hypertension. The provider failed to perform a cardiac profile laboratory study as required by the CAH's chest pain protocol.
The inability to perform these studies caused the patient to be transferred to another hospital to complete the laboratory studies for further diagnosis and treatment.


Review of Patient 3's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 01/03/19 at 6:30 AM with a complaint of chest pain. The provider failed to perform a cardiac profile laboratory study as required by the CAH's chest pain protocol. The inability to perform these studies caused the provider to arrange a transfer to another hospital to complete the laboratory studies for further diagnosis and treatment. The patient ultimately refused transfer stating she did not have insurance and left the CAH Against Medical Advice (AMA).


Review of Patient 5's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 12/30/18 at 6:09 PM with a complaint of hypertension (high blood pressure) and tachycardia (a heartrate above 100 beats per minute for an adult). The provider failed to perform a cardiac profile laboratory study as required by the CAH's chest pain protocol.


During an interview on 01/09/19 at 4:30 PM Staff K, Advanced Practice Registered Nurse (APRN) stated, "I felt Patients 2, 3, and 5 were stable for transfer based on their electrocardiogram (EKG) a test that is used to determine heart rate, heart rhythm and other information regarding the heart's condition), physical presentation, and vital signs. I felt that they needed the cardiac enzyme tests for additional care and treatment." Staff K, APRN, confirmed that she was not able to follow the chest pain protocols due to the CAH's lack of laboratory services.


Document review of the CAH Emergency Department Policy and Procedure titled, "Attempted Suicide" dated 10/2013 showed staff are required to obtain the following laboratory tests in order to have psychiatric facilities accept them for transfer: Urine Drug Screen (UDS), Tylenol level, Aspirin level, and CBC (complete blood count).


Review of Patient 1's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 01/03/19 at 8:30 PM with a complaint of Suicidal Ideation (thoughts of suicide). The provider failed to perform laboratory studies required by the CAH's policy and procedure for Suicidal patients. The inability to perform these studies caused the patient to be transferred to another hospital to complete the mental health screening exam for admission and treatment.

Review of Patient 6's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 12/30/18 at 12:25 PM with a complaint of Suicidal Ideation (thoughts of suicide). The provider failed to perform laboratory studies required by the CAH's policy and procedure for Suicidal patients. The inability to perform these studies caused the provider to arrange a transfer to another hospital to complete the laboratory studies for further diagnosis and treatment.


During an interview on 01/09/19 at 4:30 PM Staff K, Advanced Practice Registered Nurse (APRN) stated, "I was unable to complete a mental health exam due to our inability to perform laboratory tests as directed by our policies. Our mental health screeners will not provide a mental health exam without the labs." Staff K, APRN stated she felt the patients were stable for transport based on her physical exam and the SBQ-R suicide screen (a suicide risk assessment tool. A score of seven or above indicates a suicide risk), but confirmed she could not rule out underlying conditions without laboratory services.

Document review of the CAH Emergency Department Protocol titled, "Acute Pulmonary Edema" dated 10/2013 showed staff are to obtain the following laboratory studies: CBC with diff, CMP (comprehensive metabolic profile), Urinalysis, if female 12-65 years old obtain a Urine HCG (pregnancy test), D-dimer (used to help rule out the presence of an inappropriate blood clot), and cardiac enzymes.

Document review of the CAH Emergency Department Policy and Procedure titled, "Hyperglycemic Crisis Protocol" dated 01/2018, showed staff are to obtain the following laboratory studies: Arterial Blood Gas (ABG) test measures oxygen and carbon dioxide levels in your blood. It also measures your body's acid-base (pH) level) or Venous Blood Gas (VBG) blood sample taken from either peripheral or central veins -can serve as an alternative to an ABG when evaluating patients with metabolic and respiratory disturbances), CBC, CMP, Basic Metabolic Panel (BMP) is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys are working), and Urinalysis. For continued treatment repeat the VBG or ABG and the BMP every two hours. The facility providers are unable to follow their Hyperglycemic Crisis Protocol without laboratory services.


During an interview on 01/09/19 at 11:15 AM, Staff I, Physician, stated, "Without labs we cannot follow all the emergency departments policies and procedures for emergency care." Staff I stated that he would not admit patients to the CAH's inpatient unit for care if they would require monitoring with laboratory studies.

Based on observation, interview and document review the Critical Access Hospital (CAH) lacked evidence the Governing Body ensured the CAH followed the Medical Staff Bylaws requiring provision of stat and routine clinical laboratory and anatomic pathology services for hospital inpatients and outpatients and failed to ensure they provided laboratory services by agreement or arrangement for medical management of emergency medical conditions. This failure has the potential to cause poor patient outcomes.

Findings Include:

Document review of the Critical Access Hospital (CAH) "Medical Staff Bylaws," dated 04/14/03 showed, the CAH was organized for the purpose of providing health care and medical services for inpatients and outpatients and promoting the well-being of the citizens of the town and the surrounding area.

Document review of the CAH policy titled, "Laboratory; Scope of Services," dated 07/2014, showed, The Department of Laboratory Services provides stat and routine clinical laboratory and anatomic pathology services for hospital inpatients and outpatients, clinic and other non-hospital patients, and non-HCH healthcare providers. And also showed, Hours of Operation; Inpatient, Swing Bed, observation, and ER Patients: 24 hours per day, 7 days per week, and 365 days per year' and 'Scope of Services provided; clinical laboratory services, clinical laboratory reference lab services, and anatomical pathology services.

During observation on 01/07/19, 01/08/19 and 01/09/19 Staff N, phlebotomist was available for outpatient blood draws and specimen collection. No other laboratory staff was available.

During an interview on 01/07/19 at 9:30 AM Staff B, Chief Nursing Officer (CNO), stated that the hospital currently had "no lab services" in the building. The hospital has a phlebotomist and can draw blood and sends it by courier to an outside Lab in Lenexa, KS (~150 miles away). She stated that the staff was trained and able to do point of care testing to include; flu swabs, urine dipsticks, urine pregnancy, mono spot, and blood glucose with a glucometer.

During an interview on 01/07/19 at 4:30 PM, Staff H, Corporate Laboratory Staff, stated, "The CAH has a contract for a laboratory director and pathology services, but they are currently refusing to provide services because they have not been paid for a month." Staff H stated that the Corporation's Governing Body has not offered a solution for the CAH's lack of laboratory services which began on 12/28/18.


Document review of the CAH Emergency Department Policy and Procedure titled, "Chest Pain" dated 10/2013 showed, staff are to draw lab for a Cardiac Profile which includes the following: Complete Blood Count with differential (CBC) blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia), comprehensive metabolic panel (CMP) is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working), Cardiac Enzymes (measure the levels of enzymes and proteins that are linked with injury of the heart muscle. These include the enzymes creatine phosphokinase (CPK) and creatine kinase (CK), and the proteins troponin I (TnI) and troponin T (TnT), A prothrombin time (PT) is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the international normalized ratio (INR) is calculated from a PT result and is used to monitor how well the blood-thinning medication (anticoagulant) warfarin (Coumadin®) is working to prevent blood clotting (PT/INR), and A partial thromboplastin time (PTT) test is a blood test that helps doctors assess your body's ability to form blood clots.

During an interview on 01/09/19 at 4:30 PM Staff K, Advanced Practice Registered Nurse (APRN) stated, "I felt that they (patients) needed the cardiac enzyme tests for additional care and treatment." Staff K, APRN, confirmed that she was not able to follow the chest pain protocols due to the CAH's lack of laboratory services.

Document review of the CAH Emergency Department Policy and Procedure titled, "Attempted Suicide" dated 10/2013 showed staff are required to obtain the following laboratory tests in order to have psychiatric facilities accept them for transfer: Urine Drug Screen (UDS), Tylenol level, Aspirin level, and CBC (complete blood count).

During an interview on 01/09/19 at 4:30 PM Staff K, Advanced Practice Registered Nurse (APRN) stated, "I was unable to complete a mental health exam due to our inability to perform laboratory tests as directed by our policies. Our mental health screeners will not provide a mental health exam without the labs." Staff K, APRN stated she felt the patients were stable for transport based on her physical exam and the SBQ-R suicide screen (a suicide risk assessment tool. A score of seven or above indicates a suicide risk), but confirmed she could not rule out underlying conditions without laboratory services.

Document review of the CAH Emergency Department Protocol titled, "Acute Pulmonary Edema" dated 10/2013 showed staff are to obtain the following laboratory studies: CBC with diff, CMP (comprehensive metabolic profile), Urinalysis, if female 12-65 years old obtain a Urine HCG (pregnancy test), D-dimer (used to help rule out the presence of an inappropriate blood clot), and cardiac enzymes.

Document review of the CAH Emergency Department Policy and Procedure titled, "Hyperglycemic Crisis Protocol" dated 01/2018, showed staff are to obtain the following laboratory studies: Arterial Blood Gas (ABG) test measures oxygen and carbon dioxide levels in your blood. It also measures your body's acid-base (pH) level) or Venous Blood Gas (VBG) blood sample taken from either peripheral or central veins -can serve as an alternative to an ABG when evaluating patients with metabolic and respiratory disturbances), CBC, CMP, Basic Metabolic Panel (BMP) is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys are working), and Urinalysis. For continued treatment repeat the VBG or ABG and the BMP every two hours. The facility providers are unable to follow their Hyperglycemic Crisis Protocol without laboratory services.

During an interview on 01/09/19 at 11:15 AM, Staff I, Physician, stated, "Without labs we cannot follow all the emergency departments policies and procedures for emergency care." Staff I stated that he would not admit patients to the CAH's inpatient unit for care if they would require monitoring with laboratory studies.

The CAH's CEO and governing body failed to ensure the staff could provide emergency services as directed by their policies, procedures, and protocols for medical management of emergency medical conditions.

Based on interview, the Critical Access Hospital (CAH) failed to notify the State Agency of the name of the person responsible for the operation of the CAH. This deficient practice has the potential to cause ineffective communications between the CAH and the State Agency.

Findings Include:

During an interview on 01/07/19 at 9:45 AM, Staff B, Chief Nursing Officer, stated that the CAH's current interim Chief Executive Officer (CEO) was Staff A who was also the CEO at a facility in Fairfax Oklahoma. Staff B indicated that the former CEO retired in November 2018. Staff B indicated she had directed staff to notify the State Agency but acknowledged it was not done as required.

Review of State Agency Database on 01/07/19 showed the name and contact information of the former CEO as still current.

The CAH failed to notify the State Agency the CEO retired in November and to provide the name of the current CEO.

Based on observation, interview, documents, medical records and policy review the Critical Access Hospital (CAH) failed to provide laboratory services by agreement or arrangement for scientific oversight and pathology services for all patients; failed to provide laboratory services in compliance with their policies for medical management of conditions requiring consultation or patient referral; failed to provide basic laboratory services essential to immediate diagnosis and treatment of patient to meet standards of care for all patients who require a Hemoglobin and Hematocrit (H&H); and failed to hold the Chief Executive Officer (CEO )and governing body responsible for laboratory services by agreement.

The CAH's failure to ensure to provide laboratory services by agreement, to provide laboratory services for medical management of conditions requiring consultation or referral to provide basic laboratory and to provide a responsible person for services by agreement has the potential for deficient leadership, inaccuracy and safety concerns, the loss of continuity of care and poor patient outcomes, decreases hemodynamic monitoring and fails to accurately identify patient perfusion problems.


Findings Include:

Document review of the Critical Access Hospital (CAH) "Medical Staff Bylaws," dated 04/14/03, showed, the CAH was organized for the purpose of providing health care and medical services for inpatients and outpatients and promoting the well-being of the citizens of the town and the surrounding area.

Document review of the CAH policy titled, "Laboratory; Scope of Services," dated 07/2014, showed, The Department of Laboratory Services provides stat and routine clinical laboratory and anatomic pathology services for hospital inpatients and outpatients, clinic and other non-hospital patients, and non-HCH healthcare providers.' And also showed, Hours of Operation; Inpatient, Swing Bed, observation, and ER Patients: 24 hours per day, 7 days per week, and 365 days per year and Scope of Services provided; clinical laboratory services, clinical laboratory reference lab services, and anatomical pathology services.


1. The CAH failed to provide laboratory services by agreement or arrangement for scientific oversight and pathology services for all patients. (Refer to C-0273).

2. The CAH failed to provide laboratory services in compliance with their policies for medical management of conditions requiring consultation or patient referral. (Refer to C-0275).

3. The CAH failed to provide basic laboratory services essential to immediate diagnosis and treatment of patients to meet standards of care for all patient who require a Hemoglobin and Hematocrit (H&H). (Refer to C-0282).

4. The CEO and the governing body failed to provide laboratory services by agreement or arrangement for scientific oversight and pathology services for all patients. (Refer to C-0292).

Based on interview, document and policy review the Critical Access Hospital (CAH) failed to provide laboratory services by agreement or arrangement for scientific oversight and pathology services for all patients. The CAH's failure to ensure to provide laboratory services by agreement has the potential for inaccuracy and safety concerns with laboratory testing and the handling and preparation of specimens.

Findings Include:

Document review of the Critical Access Hospital (CAH) titled, "Medical Staff Bylaws," dated 04/14/03, showed the CAH was organized 'for the purpose of providing health care and medical services for inpatients and outpatients and promoting the well-being of the citizens of the town and the surrounding area.'

Document review of the CAH policy titled, "Laboratory; Scope of Services," dated 07/2014, showed, The Department of Laboratory Services provides stat and routine clinical laboratory and anatomic pathology services for hospital inpatients and outpatients, clinic and other non-hospital patients, and non-HCH healthcare providers. And also showed, Hours of Operation; Inpatient, Swing Bed, observation, and ER Patients: 24 hours per day, 7 days per week, and 365 days per year and Scope of Services provided; clinical laboratory services, clinical laboratory reference lab services, and anatomical pathology services.

During observation on 01/07/19, 01/08/19 and 01/09/19 Staff N, phlebotomist was available for outpatient blood draws and specimen collection. No other laboratory staff was available.

During an interview on 01/07/19 at 9:30 AM Staff B, Chief Nursing Officer (CNO), stated that the hospital currently had "no lab services" in the building. The hospital has a phlebotomist and is able to draw blood and sends it by courier to an outside Lab in Lenexa, KS (~150 miles away). She stated that the staff was trained and able to do point of care testing to include; flu swabs, urine dipsticks, urine pregnancy, mono spot, and blood glucose with a glucometer.

During an interview on 01/07/19 at 2:00 PM Staff H, corporate laboratory representative, stated that he has worked with the governing body corporation for 14 years. He stated that he had a conversation with the executive team on December 28, 2018 when the laboratory manager "walked out". The hospital notified ambulance services and placed the hospital on laboratory diversion. Staff H stated that they are looking at other facilities within the corporation for laboratory staff and support; there is a terrible shortage of laboratory staff other places too. He stated that another option they're looking at is to "get the contracted lab staff back in here; they have two laboratory staff that are trained on our laboratory equipment." Staff H stated that the point of care testing the hospital staff could do now was fecal occult, urine dipstick, urine pregnancy, Influenza A and B swab, strep screening and blood glucose by glucometer. He stated that the hospital staff could not perform a Hemoglobin and Hematocrit (H&H).

During an interview on 01/07/19 at 4:30 PM Staff H, stated that "We have a contract with Heartland Pathology for Pathology services, lab director, and education. However, they have not been paid in a month and are currently refusing to take our calls until they receive payment."

During an interview on 01/07/19 at 1030 Staff N, phlebotomist stated that she was hired to draw blood and wasn't trained on any of the laboratory equipment. Staff N stated that she draws blood for the outpatients. She stated that she was to "draw, process and ship." She stated that the lab specimens are picked up by a currier every day, Monday through Friday and taken to Lenexa. Results may be available by 8:00 or 10:00 PM. The currier may pick up on a Saturday if he was called in.

Based on interview, medical record and policy review the Critical Access Hospital (CAH) failed to provide laboratory services in compliance with their policies for medical management of conditions requiring consultation or patient referral. These patient conditions include; chest pain, suicide ideation, hyperglycemia and pulmonary edema.

The CAH's failure to ensure to provide laboratory services for medical management of conditions which require consultation or referral has the potential for loss of continuity of care and poor patient outcomes.

Findings Include:

Document review of the Critical Access Hospital (CAH) "Medical Staff Bylaws," dated 04/14/03, showed the CAH was organized for the purpose of providing health care and medical services for inpatients and outpatients and promoting the well-being of the citizens of the town and the surrounding area.

Document review of the CAH policy titled, "Laboratory; Scope of Services," dated 07/2014, showed, The Department of Laboratory Services provides stat and routine clinical laboratory and anatomic pathology services for hospital inpatients and outpatients, clinic and other non-hospital patients, and non-HCH healthcare providers. And also showed, Hours of Operation; Inpatient, Swing Bed, observation, and ER Patients: 24 hours per day, 7 days per week, and 365 days per year' and 'Scope of Services provided; clinical laboratory services, clinical laboratory reference lab services, and anatomical pathology services.

During observation on 01/07/19, 01/08/19 and 01/09/19 Staff N, phlebotomist was available for outpatient blood draws and specimen collection. No other laboratory staff was available.

During an interview on 01/07/19 at 9:30 AM Staff B, Chief Nursing Officer (CNO), stated that the hospital currently had "no lab services" in the building. The hospital has a phlebotomist and is able to draw blood and sends it by courier to an outside Lab in Lenexa, KS (~150 miles away). She stated that the staff was trained and able to do point of care testing to include; flu swabs, urine dipsticks, urine pregnancy, mono spot, and blood glucose with a glucometer.

During an interview on 01/07/19 at 2:00 PM Staff H, corporate laboratory representative, stated that he has worked with the governing body corporation for 14 years. He stated that he had a conversation with the executive team on December 28, 2018 when the laboratory manager "walked out". The hospital notified ambulance services and placed the hospital on laboratory diversion. Staff H stated that they are looking at other facilities within the corporation for laboratory staff and support; there is a terrible shortage of laboratory staff other places too. He stated that another option they're looking at is to "get the contracted lab staff back in here; they have two laboratory staff that are trained on our laboratory equipment." Staff H stated that the point of care the hospital staff could do was fecal occult, urine dipstick, urine pregnancy, Influenza A and B swab, strep screening and blood glucose by glucometer. He stated that the hospital staff could not perform a Hemoglobin and Hematocrit (H&H).

During an interview on 01/07/19 at 1030 Staff N, phlebotomist stated that she was hired to draw blood and wasn't trained on any of the laboratory equipment. Staff N stated that she draws blood for the outpatients. She stated that she was to "draw, process and ship." She stated that the lab specimens are picked up by a currier every day, Monday through Friday and taken to Lenexa. Results may be available by 8:00 or 10:00 PM. The courier may pick up on a Saturday if he was called in.


Review of Patient 1's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 01/03/19 at 8:30 PM with a complaint of Suicidal Ideation (thoughts of suicide). The provider failed to perform laboratory studies required by the CAH's policy and procedure for Suicidal patients. The inability to perform these studies caused the patient to be transferred to another hospital to complete the mental health screening exam for admission and treatment.


Review of Patient 2's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 01/03/19 at 11:55 AM with the following complaints: dizziness, clammy, and hypertension. The provider failed to perform a cardiac profile laboratory study as required by the CAH's chest pain protocol. The inability to perform these studies caused the patient to be transferred to another hospital to complete the laboratory studies for further diagnosis and treatment.


Review of Patient 3's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 01/03/19 at 6:30 AM with a complaint of chest pain. The provider failed to perform a cardiac profile laboratory study as required by the CAH's chest pain protocol. The inability to perform these studies caused the provider to arrange a transfer to another hospital to complete the laboratory studies for further diagnosis and treatment. The patient ultimately refused transfer stating she did not have insurance and left the CAH Against Medical Advice (AMA).


Review of Patient 5's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 12/30/18 at 6:09 PM with a complaint of hypertension (high blood pressure) and tachycardia (a heartrate above 100 beats per minute for an adult). The provider failed to perform a cardiac profile laboratory study as required by the CAH's chest pain protocol. The inability to perform these studies caused the provider to arrange a transfer to another hospital to complete the laboratory studies for further diagnosis and treatment.


Review of Patient 6's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 12/30/18 at 12:25 PM with a complaint of Suicidal Ideation (thoughts of suicide). The provider failed to perform laboratory studies required by the CAH's policy and procedure for Suicidal patients.The inability to perform these studies caused the provider to arrange a transfer to another hospital to complete the laboratory studies for further diagnosis and treatment.

Based on observation and interview the Critical Access Hospital (CAH) failed to provide basic laboratory services essential to immediate diagnosis and treatment of patients to meet standards of care for all patient who require a Hemoglobin and Hematocrit (H&H). The CAH's failure to ensure the basic laboratory services include an H&H has the potential for: decreased hemodynamic monitoring; failure to accurately identify a decrease in patient perfusion; and inability to correctly monitor the patient's ability for oxygen carrying capacity of their blood.

Findings Include:

Document review of the Critical Access Hospital (CAH) "Medical Staff Bylaws," dated 04/14/03 showed, the CAH was organized 'for the purpose of providing health care and medical services for inpatients and outpatients and promoting the well-being of the citizens of the town and the surrounding area.'

Document review of the CAH policy titled, "Laboratory; Scope of Services," dated 07/2014, showed, The Department of Laboratory Services provides stat and routine clinical laboratory and anatomic pathology services for hospital inpatients and outpatients, clinic and other non-hospital patients, and non-HCH healthcare providers. And also showed, Hours of Operation; Inpatient, Swing Bed, observation, and ER Patients: 24 hours per day, 7 days per week, and 365 days per year and Scope of Services provided; clinical laboratory services, clinical laboratory reference lab services, and anatomical pathology services.

During observation on 01/07/19, 01/08/19 and 01/09/19 Staff N, phlebotomist was available for outpatient blood draws and specimen collection. No other laboratory staff was available.

During an interview on 01/07/19 at 9:30 AM Staff B, Chief Nursing Officer (CNO), stated that the hospital currently had "no lab services" in the building. The hospital has a phlebotomist and is able to draw blood and sends it by courier to an outside Lab in Lenexa, KS (~150 miles away). She stated that the staff was trained and able to do point of care testing to include; flu swabs, urine dipsticks, urine pregnancy, mono spot, and blood glucose with a glucometer.

During an interview on 01/07/19 at 2:00 PM, Staff H, corporate laboratory representative, stated that he has worked with the governing body corporation for 14 years. He stated that he had a conversation with the executive team on December 28, 2018 when the laboratory manager "walked out". The hospital notified ambulance services and placed the hospital on laboratory diversion. Staff H stated that they are looking at other facilities within the corporation for laboratory staff and support; there is a terrible shortage of laboratory staff other places too. He stated that another option they're looking at is to "get the contracted lab staff back in here; they have two laboratory staff that are trained on our laboratory equipment." Staff H stated that the point of care the hospital staff could do was fecal occult, urine dipstick, urine pregnancy, Influenza A and B swab, strep screening and blood glucose by glucometer. He stated that the hospital staff could not perform a Hemoglobin and Hematocrit (H&H).

During an interview on 01/07/19 at 1030 Staff N, phlebotomist stated that she was hired to draw blood and wasn't trained on any of the laboratory equipment. Staff N stated that she draws blood for the outpatients. She stated that she was to "draw, process and ship." She stated that the lab specimens are picked up by a currier every day, Monday through Friday and taken to Lenexa. Results may be available by 8:00 or 10:00 PM. The courier may pick up on a Saturday if he was called in.


Review of Patient 1's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 01/03/19 at 8:30 PM with a complaint of Suicidal Ideation (thoughts of suicide). The provider failed to perform laboratory studies required by the CAH's policy and procedure for Suicidal patients. The inability to perform these studies caused the patient to be transferred to another hospital to complete the mental health screening exam for admission and treatment.


Review of Patient 2's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 01/03/19 at 11:55 AM with the following complaints: dizziness, clammy, and hypertension. The provider failed to perform a cardiac profile laboratory study as required by the CAH's chest pain protocol. The inability to perform these studies caused the patient to be transferred to another hospital to complete the laboratory studies for further diagnosis and treatment.


Review of Patient 3's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 01/03/19 at 6:30 AM with a complaint of chest pain. The provider failed to perform a cardiac profile laboratory study as required by the CAH's chest pain protocol. The inability to perform these studies caused the provider to arrange a transfer to another hospital to complete the laboratory studies for further diagnosis and treatment. The patient ultimately refused transfer stating she did not have insurance and left the CAH Against Medical Advice (AMA).


Review of Patient 5's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 12/30/18 at 6:09 PM with a complaint of hypertension (high blood pressure) and tachycardia (a heartrate above 100 beats per minute for an adult). The provider failed to perform a cardiac profile laboratory study as required by the CAH's chest pain protocol. The inability to perform these studies caused the provider to arrange a transfer to another hospital to complete the laboratory studies for further diagnosis and treatment.


Review of Patient 6's discharged medical record on 01/08/19 at 10:00 AM, showed they were admitted on 12/30/18 at 12:25 PM with a complaint of Suicidal Ideation (thoughts of suicide). The provider failed to perform laboratory studies required by the CAH's policy and procedure for Suicidal patients. The inability to perform these studies caused the provider to arrange a transfer to another hospital to complete the laboratory studies for further diagnosis and treatment.

Based on observation, interview and document review the Chief Executive Officer (CEO) and the governing body failed to provide laboratory services by agreement or arrangement for scientific oversight and pathology services for all patients. The CEO and governing body's failure to ensure to provide laboratory services by agreement or arrangement for oversight and pathology services has the potential for inaccuracy and safety concerns with laboratory testing and the handling and preparation of specimens.

Findings Include:

Document review of the Critical Access Hospital (CAH) "Medical Staff Bylaws," dated 04/14/03, showed the CAH was organized 'for the purpose of providing health care and medical services for inpatients and outpatients and promoting the well-being of the citizens of the town and the surrounding area.'

Document review of the CAH policy titled, "Laboratory; Scope of Services," dated 07/2014, showed, The Department of Laboratory Services provides stat and routine clinical laboratory and anatomic pathology services for hospital inpatients and outpatients, clinic and other non-hospital patients, and non-HCH healthcare providers. And also showed, Hours of Operation; Inpatient, Swing Bed, observation, and ER Patients: 24 hours per day, 7 days per week, and 365 days per year and Scope of Services provided; clinical laboratory services, clinical laboratory reference lab services, and anatomical pathology services.

During observation on 01/07/19, 01/08/19 and 01/09/19 Staff N, phlebotomist was available for outpatient blood draws and specimen collection. No other laboratory staff was available.

During an interview on 01/07/19 at 9:30 AM Staff B, Chief Nursing Officer (CNO), stated that the hospital currently had "no lab services" in the building. The hospital has a phlebotomist and is able to draw blood and sends it by currier to an outside Lab in Lenexa, KS (~150 miles away). She stated that the staff was trained and able to do point of care testing to include; flu swabs, urine dipsticks, urine pregnancy, mono spot, and blood glucose with a glucometer.

During an interview on 01/07/19 at 2:00 PM Staff H, corporate laboratory representative, stated that he has worked with the governing body corporation for 14 years. He stated that he had a conversation with the executive team on December 28, 2018 when the laboratory manager "walked out". The hospital notified ambulance services and placed the hospital on laboratory diversion. Staff H stated that they are looking at other facilities within the corporation for laboratory staff and support; there is a terrible shortage of laboratory staff other places too. He stated that another option they're looking at is to "get the contracted lab staff back in here; they have two laboratory staff that are trained on our laboratory equipment." Staff H stated that the point of care the hospital staff could do was fecal occult, urine dipstick, urine pregnancy, Influenza A and B swab, strep screening and blood glucose by glucometer. He stated that the hospital staff could not perform a Hemoglobin and Hematocrit (H&H).

During an interview on 01/07/19 at 4:30 PM Staff H, stated, "We have a contract with Heartland Pathology for Pathology services, lab director, and education. However, they have not been paid in a month and are currently refusing to take our calls until they receive payment."

During an interview on 01/07/19 at 1030 Staff N, phlebotomist stated that she was hired to draw blood and wasn't trained on any of the laboratory equipment. Staff N stated that she draws blood for the outpatients. She stated that she was to "draw, process and ship." She stated that the lab specimens are picked up by a currier every day, Monday through Friday and taken to Lenexa. Results may be available by 8:00 or 10:00 PM. The currier may pick up on a Saturday if he was called in.