HospitalInspections.org

Based on review of Medical Staff Bylaws/Rules and Regulations, Meeting minutes of the Medical Staff, Current Roster of Medical Staff Members 2017-2018, list of dates the hospital Emergency Department (ED) was on diversion because no physician was available, facility policy, EMS (Emergency Medical Services) Run Report, Registered Nurse (RN) personnel files, Job Descriptions, medical records and interviews, it was determined the Governing Body failed to ensure:

1. The medical staff was accountable to Governing Body for the quality of care provided to patients.

2. There was a physician available to provide ED services at all times.

3. The emergency department followed it's policy for diversion, in that:

a. There was no documentation the staff notified the local EMS (Emergency Medical Services) representative the hospital was on diversion.

b. The policy for diversion did not specify the number of hours the facility would update EMS with diversion status.

c. The facility was not on diversion greater than 6 hours in a 24 hour period or received approval from the local on-call EMS representative for diversion greater than 6 hours.

d. The facility conducted an internal review of the diversion, including causative factors and efforts undertaken to avoid the diversion, and submit a written critique to the local EMS office within a 72-hour period.

e. The facility staff failed to follow their policy related to the exceptions to diversion for Patient Indentifer (PI) # 1, a patient who was experiencing a cardiac arrest with EMS requesting assistance to stabilize the patient.

4. The emergency department was staffed 24 hours a day with nursing personnel who were currently certified in BCLS (Basic Cardiopulmonary life support), ACLS (Advanced cardiac Life support) and/or PALS (Pediatric Advanced Life Support).

5. There was an active Chief of Staff elected by the Medical Staff.

6. The Medical Staff committee actively participated in monthly meetings to evaluate the care provided by the physicians for the hospital.

7. The facility had an organized Medical Staff committee to meet the needs of the patients.

8. The facility Emergency Department was under the direction of a Medical Staff member.

Findings include:

Refer to A 049, A 091, A 338, A 353, A 356, A 1110, A 1102, A 1104, A 1110, and A 1112 for findings.

Based on review of Medical Staff Bylaws/Rules and Regulations, Meeting minutes of the Medical Staff and interview with Employee Identifier (EI) # 1, Administrator and EI # 3, Chief of Staff, it was determined the governing body failed to ensure the medical staff was accountable to governing body for the quality of care provided to patients.

Findings include:

Review of the Medical Staff Bylaws and Rules and Regulations of Hill Hospital of Sumter County which were reviewed by the Administrator on 4/4/17, Chairman of the Governing Board on 4/18/17 and Chief of Staff/Assistant Chief of Staff on 4/26/17 revealed:
... Preamble

...Whereas, its purpose is to serve as an acute care general hospital providing patient care, education and research; and

Whereas, it is recognized that one of the aims and goals of the Medical Staff is to strive for optimal achievable quality patient care in the Hospital, that the Medical Staff must cooperate with and is subject to the ultimate authority of the Governing Board, and that the cooperative efforts of the Medical Staff, Management, and the Governing Board are necessary to fulfill the Hospital's aims and goals in the Hospital;

Therefore, the physicians and dentist practicing in Hill Hospital of Sumter County, hereby organize themselves into a Medical Staff in conformity with these Bylaws ...

Article II Purposes and Responsibilities

2.1 Purposes

The purposes of the Medical Staff are:

2.1-1 To ensure that all patients admitted to or treated in any of the facilities, departments, or services of the Hospital shall receive optimal achievable quality patient care commensurate with available resources.

2.1-2 To service as a primary means for accountability to the Board to ensure an optimal level of professional performance of all practitioners authorized to practice in the Hospital through the appropriate delineation of the clinical privileges and through ongoing review and evaluation of each practitioner's performance in the Hospital;

2.1-3 To serve as a means of accountability and reporting of results to the Board of patient care evaluation continued monitoring and other quality assurance activities in accordance with the Hospital's quality assurance plan ...

2.1-5 To initiate and maintain rules and regulations for the proper functioning of the Medical Staff; and

2.1-6 To provide a means whereby issues concerning the Medical Staff with the Board and administrator ...

2.2 Responsibilities

2.2-1 To account for the quality and appropriateness of patient care rendered by all practitioners ... authorized to practice in the Hospital through the following measures:

...(d) An organizational structure that allows continuous monitoring of patient care practices;

(e) Patient care evaluation of the quality of patient care and the reporting of results to the Board ...

(g) To develop, administer and see compliance with these Bylaws, the Rules and Regulations of the Staff; and other medical care related current Hospital policies;

(h) To assist in identifying community health needs and in setting appropriate institutional goals and implementing programs to meet those needs; and

(i) To exercise the authority granted by these Bylaws as necessary to adequately fulfill the foregoing responsibilities ...

Article XI Officers
11.1 Officers of the Staff

11.1-1 Identification
The officers of the Staff shall be:
(a) Chief of Staff
(b) Vice Chief of Staff
( c) Secretary/Treasurer

11.1-2 Qualifications

Officers must be members of the Active Staff at a time of nomination and election and must remain members in good standing during their term of office ...

11.1-3 Election
Officers shall be elected at the annual meeting of the Staff in December. Only Staff accorded the prerogative to vote for general Staff officers under Article IV shall be eligible to vote. Voting shall be by ballot. An officer shall be elected upon receiving a majority of the valid votes cast ...

11.1-5 Vacancies in Elected Office
Vacancies in offices, other than those of the Chief of Staff and Vice Chief of Staff shall be filled by the Medical Staff. If there is a vacancy in the office of Chief of Staff, the Vice Staff shall serve out the remaining term. A vacancy in the office of Vice Chief of Staff shall be filled by the Secretary/Treasurer.

11.1-6 Duties of Elected Officers
(a) The Chief of Staff shall serve as the Chief Medical Officer and principal elected official of the Staff. As much, he shall:
(1) Aid in coordinating the activities and concerns of the Hospital administration and of the nursing and other non-physician patient care services with those of the Medical Staff;
(2) Be responsible to the Board, in conjunction with the Medical Staff, for the quality and efficiency of clinical services and professional performances within the Hospital and for the effectiveness of patient care evaluations and the quality assurance functions delegated to the Staff ...
(7) Call, preside at, and be responsible for the agenda of all general meetings of the Medical Staff ...

(8) Serve as a member of the Board of Trustees at the discretion of the Board.

(b) Vice Chief of Staff:
... responsible for the Bylaws and Joint Conference Function. In temporary absence of the Chief of Staff, he shall assume all the duties and have authority of the Chief of Staff. He shall perform such additional duties as may be assigned to him by the Chief of Staff, the Medical Staff or the Board ...

( c) Secretary/Treasurer
... shall be a member of the Medical Staff and a member of all other Staff committees or functions ... duties shall be to:
(1) Give proper notice of all Staff meetings on order of the appropriate authority.
(2) Prepare accurate and complete minutes for all meetings ...

Article XII Committees and Functions ...

12.2 Committee of the Whole

12.2-1 Composition
The Committee of the Whole shall consist of all the members of the Medical Staff. The Chief of Staff shall be its Chairman and shall preside at meetings ...

12.2-3 Duties:
The Duties of the Committee of the Whole shall be to:
a. Receive and act upon reports and recommendations from the functions, special committees and officers of the staff concerning patient care evaluation and other quality assurance activities and the discharge of their delegated medical administrative responsibilities ...

d. Account to the Board for the overall quality and efficiency of medical care rendered to patients in the hospital ...

g. Participate in identifying community health needs and in setting Hospital goals and implementing programs to meet those needs.

12.2-4 Meetings
The Medical staff shall meet at least once a month and maintain a permanent record of its proceedings and actions ...

12.4 Description of Functions
12/4-1 Patient Care Evaluation (Quality Improvement)
The duties involved in performing patient care evaluation are:
(a) Adopt specific programs and procedures for the identification and resolution of problems that impact the quality of patient care in order to maintain the desired quality, efficiency, and effectiveness of patient care within the Hospital. The findings and results of these assessment activities shall be reported to the Medical Staff.

(b) Patient care evaluations shall include medical and/or multi-disciplinary studies as well as clinical service studies designed to evaluate the quality and appropriateness of patient care within each clinical service;

(c ) Patient care evaluation shall be performed in accordance with the Hospital's quality assurance plan ...

12.4-11 Safety
The Staff member's duties involved in the Hospital's multi-disciplinary safety committee are to:

(a) Participate in the program of staffing, equipping, operating, and maintaining the hospital designed to produce safe characteristics and practices and to eliminate or reduce the extent possible, hazards to patients, Hospital Staff, and visitors ...

(e) The Safety Committee will meet on a quarterly basis ...

Article XIII Meetings

13.1 Annual Staff Meetings

13.1-1 Meeting time
The annual Staff Meeting shall be held at least one (1) day before the end of the Medical Staff year and shall replace the December meeting of the Medical Staff.

13.1-2 Order of Business and Agenda
The order of business at an annual meeting shall be determined by the Chief of Staff. The agenda shall include at least:
(a) Reading and acceptance of the minutes of the last regular and of all special meetings since the last regular meeting;
(b) Administrative reports from the Administrator, the Chief of Staff, and appropriate committee chairman;

(c ) The election of officers and other officers of the Medical Staff when required by these Bylaws ...

(e) Recommendations for maintenance and/or improvement of patient care ...

13.2 Regular Staff Meetings

13.2-1 Meeting Time

The Medical Staff may, by resolution, provide the time for holding regular meetings ... The frequency of such meetings shall be as required by these Bylaws, but shall be at least once a month ...

13.4 Quorum

13.4-1 General Staff Meeting
The presence of a majority of the voting members of the Active Medical Staff at any regular or special meeting shall constitute a quorum for the purpose of amendment to these Bylaws, or shall constitute a quorum for the transaction of all other business. This quorum must be found before any action may be taken, but once found, the business of the meeting may continue and all actions taken thereafter shall be binding even though less than a quorum may be present at a later time in the meeting.

13.4-2 Department and Committee Meetings
A majority of the voting members of a committee, but not less than two members, shall constitute a quorum at any meeting of such committee ...

13.7 Attendance Requirements

13.7.1 Regular Attendance
Each member of a Staff category required to attend meetings under Article IV shall be required to attend:
(a) The Annual Medical Staff meeting.
(b) At least 60 percent of all other Medical Staff meetings duly convened pursuant to these Bylaws; and
(c ) At least 50 percent of all meetings of each committee of which he is a member ...

The surveyor requested the Meeting minutes of the Medical staff for December 2016 to ensure the election of medical staff members, including Chief of Staff, Vice Chief of Staff and Secretary/Treasurer.

Review of the Meeting minutes of the Medical Staff revealed the last meeting for 2017 was conducted on May 2, 2017.

An interview was conducted on 1/11/8 at 10:08 AM with EI # 1, who stated there was no other documentation of Medical Staff meetings for 2017 because, "EI # 11, former Chief of Staff was ineffective." The surveyor asked about EI # 11 and documentation of being the Chief of Staff. EI # 1 stated, "He got ill...not on the schedule since May/June".

An email response from the facility was received on 1/18/18 related to the Medical Staff Meeting for December 2016, which revealed, "There was no Medical Staff Meeting held December 2016."

There was no documentation of an annual meetings of the Medical Staff in December 2016 or 2017 to elected the Medical Staff Officers.

An interview was conducted on 1/19/18 at 9:31 AM with EI # 3, who verified there was no documentation of Medical Staff Meetings since May 2017. EI # 3 stated that he thought the medical staff tries to meet at least every 3 months.

Based on the review of the list of dates the hospital Emergency Department (ED) was on diversion because no physician was available, Governing Body Meeting Minutes and interviews, it was determined the Governing Body and the Medical Staff failed to ensure there was a physician available to provide ED services at all times.

Findings include:

The surveyor requested the date and times the facility went on diversion beginning September 1, 2017 to current on 1/9/18 at 11:00 AM. Employee Indentifer (EI) # 9, Quality Manager submitted an hand written sheet on 1/9/18 at 12:00 PM with jumbled up dates and no documentation of the diversion times.

The surveyor requested the dates with specific times from 9/1/17 to current. EI # 9 submitted a log that included the following days and times the hospital was on diversion because of no physician in the facility:

9/1/17 = 6 AM to 6 AM, which was 24 hours
9/5/17 = 6 AM to 6 AM
9/6/17 = 6 AM to 6 PM, which was 36 hours
9/19/17 = 6 AM to 6 AM
9/20/17 = 6 AM to 6 AM
9/21/17 = 6 AM to 6 PM, which was 60 hours
9/26/17 = 6 AM to 6 AM
9/27/17 = 6 AM to 6 PM, which was 36 hours
10/4/17 = 6 AM to 6 PM, which was 12 hours
10/7/17 = 1 PM to 6 AM, which was 17 hours
10/18/17 = 6 AM to 6 AM
10/19/17 = 6 AM to 6 AM, which was 48 hours
10/21/17 = 6 AM to 6 PM, which was 12 hours
11/1/17 = 6 AM to 6 PM, which was 12 hours
11/2/17 = 6 PM to 6 AM
11/3/17 = 6 AM to 6 AM
11/4/17 = 6 AM to 6 AM
11/5/17 = 6 AM to 6 AM, which was 84 hours
11/9/17 = 6 PM to 6 AM
11/10/17 = 6 AM to 6 AM, which was 36 hours
12/24/17 = 6 AM to 6 AM
12/25/17 = 6 AM to 6 AM, which was 24 hours
1/2/18 = 6 AM to 6 AM, which was 24 hours
1/9/18 = 6 AM to 6 AM
1/10/18 = 6 AM to 6 PM, which was 36 hours

An interview was conducted on 1/9/18 at 10:15 AM with EI # 4, ED Registered Nurse (RN). The surveyor asked if there was a physician in the ED at the present time. EI # 4 stated, "Right now I do not have an ED physician." The surveyor asked what the staff do when there is no ED physician. EI # 4 stated, "I will call the ambulance and have them take the patient to another hospital. If an ambulance calls I tell them we are on diversion and to take the patient some where else. We call the EMTs (Emergency Medical Technicians) when we know we are on diversion." The surveyor then asked to see documentation of when the EMTs were notified the hospital was on diversion. EI # 4 stated there was none.

Review of the Governing Body Meeting Minutes dated October 17, 2017 revealed no documentation the Governing Body discussed the lack of a physician in the ED.

Review of the Governing Body Meeting Minutes dated November 21, 2017 revealed documentation that the EI # 1, Administrator introduced EI # 3 as the Chief of Staff. There was no documentation EI # 3 was voted in as Chief of Staff.

Further review of the Governing Body Meeting Minutes dated November 21, 2017 revealed EI # 3 wanted to look at the relationships with old doctors and a board member would like for doctors to get paid when they had completed call in the ED. The minutes include that EI # 1 and EI # 3 continued to talk about ED coverage. There was no documentation what was discussed.

Review of the Governing Body Meeting Minutes dated December 19, 2017 revealed no documentation the Governing Body discussed the lack of a physician in the ED.

Based on review of facility policy, documentation submitted by the facility related to diversion dates and times, EMS (Emergency Medical Services) Run Report, Registered Nurse (RN) personnel files, Job Descriptions, medical records and interviews with facility staff, it was determined the Governing Body failed:

1. To ensure the emergency department followed it's policy for diversion, in that:

a. There was no documentation the staff notified the local EMS representative.

b. The policy for diversion did not specify the number of hours the facility would update EMS with diversion status.

c. The facility was not on diversion greater than 6 hours in a 24 hour period or received approval from the local on-call EMS representative for diversion greater than 6 hours.

d. The facility conducted an internal review of the diversion, including causative factors and efforts undertaken to avoid the diversion, and submit a written critique to the local EMS office within 72-hour period.

e. The facility staff failed to follow their policy related to the exceptions to diversion for Patient Indentifer (PI) # 1, a patient who was experiencing a cardiac arrest with EMS requesting assistance to stabilize the patient.

2. To ensure the emergency department was staffed 24 hours a day with nursing personnel who were currently certified in BCLS (Basic Cardiopulmonary Life Support), ACLS (Advanced Cardiac Life Support) and/or PALS (Pediatric Advanced Life Support).

3. To ensure the emergency department was staffed with Emergency Department (ED) physicians.

Findings include:

Refer to A 1104, A 1110, and A 1112 for findings.

Based on review of Medical Staff Bylaws/Rules and Regulations, Current Roster of Medical Staff Members 2017-2018, Meeting minutes of the Medical Staff and interviews, it was determined:

1. The Medical Staff was not accountable to Governing Body for the quality of care provided to patients.

2. The facility did not have an organized Medical Staff committee to meet the needs of the patients.

3. There was no active Chief of Staff elected by the Medical Staff.

4. The Medical Staff committee failed to actively participate in monthly meetings to evaluate the care provided by the physicians for the hospital.

Findings include:

Refer to A 353 and A 356 for findings.

Based on review of Medical Staff Bylaws/Rules and Regulations, Meeting minutes of the Medical Staff and interviews, it was determined the Governing Body failed to ensure:

1. The Medical Staff was accountable to Governing Body for the quality of care provided to patients.

2. There was an active Chief of Staff elected by the Medical Staff.

3. The Medical Staff actively participated in monthly meetings to evaluate the care provided by the hospital.

Findings include:

Review of the Medical Staff Bylaws and Rules and Regulations of Hill Hospital of Sumter County which were reviewed by the Administrator on 4/4/17, Chairman of the Governing Board on 4/18/17 and Chief of Staff /Assistant Chief of Staff on 4/26/17 revealed:
... Preamble

...Whereas, its purpose is to serve as an acute care general hospital providing patient care, education and research; and

Whereas, it is recognized that one of the aims and goals of the Medical Staff is to strive for optimal achievable quality patient care in the Hospital, that the Medical Staff must cooperate with and is subject to the ultimate authority of the Governing Board, and that the cooperative efforts of the Medical Staff, Management, and the Governing Board are necessary to fulfill the Hospital's aims and goals in the Hospital;

Therefore, the physicians and dentist practicing in Hill Hospital of Sumter Count, hereby organize themselves into a Medical Staff in conformity with these Bylaws ...

Article II Purposes and Responsibilities

2.1 Purposes

The purposes of the Medical Staff are:

2.1-1 To ensure that all patients admitted to or treated in any of the facilities, departments, or services of the Hospital shall receive optimal achievable quality patient care commensurate with available resources.

2.1-2 To service as a primary means for accountability to the Board to ensure an optimal level of professional performance of all practitioners authorized to practice in the Hospital through the appropriate delineation of the clinical privileges and through ongoing review and evaluation of each practitioner's performance in the Hospital;

2.1-3 To serve as a means of accountability and reporting of results to the Board of patient care evaluation continued monitoring and other quality assurance activities in accordance with the Hospital's quality assurance plan ...

2.1-5 To initiate and maintain rules and regulations for the proper functioning of the Medical Staff; and

2.1-6 To provide a means whereby issues concerning the Medical Staff with the Board and administrator ...

2.2 Responsibilities

2.2-1 To account for the quality and appropriateness of patient care rendered by all practitioners ... authorized to practice in the Hospital through the following measures:

...(d) An organizational structure that allows continuous monitoring of patient care practices;

(e) Patient care evaluation of the quality of patient care and the reporting of results to the Board ...

(g) To develop, administer and see compliance with these Bylaws, the Rules and Regulations of the Staff; and other medical care related current Hospital policies;

(h) To assist in identifying community health needs and in setting appropriate institutional goals and implementing programs to meet those needs; and

(i) To exercise the authority granted by these Bylaws as necessary to adequately fulfill the foregoing responsibilities ...

Article XI Officers
11.1 Officers of the Staff

11.1-1 Identification
The officers of the Staff shall be:
(a) Chief of Staff
(b) Vice Chief of Staff
( c) Secretary/Treasurer

11.1-2 Qualifications

Officers must be members of the Active Staff at a time of nomination and election and must remain members in good standing during their term of office ...

11.1-3 Election
Officers shall be elected at the annual meeting of the Staff in December. Only Staff accorded the prerogative to vote for general Staff officers under Article IV shall be eligible to vote. Voting shall be by ballot. An officer shall be elected upon receiving a majority of the valid votes cast ...

11.1-5 Vacancies in Elected Office
Vacancies in offices, other than those of the Chief of Staff and Vice Chief of Staff shall be filled by the Medical Staff. If there is a vacancy in the office of Chief of Staff, the Vice Staff shall serve out the remaining term. A vacancy in the office of Vice Chief of Staff shall be filled by the Secretary/Treasurer.

11.1-6 Duties of Elected Officers
(a) The Chief of Staff shall serve as the Chief Medical Officer and principal elected official of the Staff. As much, he shall:
(1) Aid in coordinating the activities and concerns of the Hospital administration and of the nursing and other non-physician patient care services with those of the Medical Staff;
(2) Be responsible to the Board, in conjunction with the Medical Staff, for the quality and efficiency of clinical services and professional performances within the Hospital and for the effectiveness of patient care evaluations and the quality assurance functions delegated to the Staff ...
(7) Call, preside at, and be responsible for the agenda of all general meetings of the Medical Staff ...

(8) Serve as a member of the Board of Trustees at the discretion of the Board.

(b) Vice Chief of Staff:
... responsible for the Bylaws and Joint Conference Function. In temporary absence of the Chief of Staff, he shall assume all the duties and have authority of the Chief of Staff. He shall perform such additional duties as may be assigned to him by the Chief of Staff, the Medical Staff or the Board ...

( c) Secretary/Treasurer
... shall be a member of the Medical Staff and a member of all other Staff committees or functions ... duties shall be to:
(1) Give proper notice of all Staff meetings on order of the appropriate authority.
(2) Prepare accurate and complete minutes for all meetings ...

Article XII Committees and Functions ...

12.2 Committee of the Whole

12.2-1 Composition
The Committee of the Whole shall consist of all the members of the Medical Staff. The Chief of Staff shall be its Chairman and shall preside at meetings ...

12.2-3 Duties:
The Duties of the Committee of the Whole shall be to:
a. Receive and act upon reports and recommendations from the functions, special committees and officers of the staff concerning patient care evaluation and other quality assurance activities and the discharge of their delegated medical administrative responsibilities ...

d. Account to the Board for the overall quality and efficiency of medical care rendered to patients in the hospital ...

g. Participate in identifying community health needs and in setting Hospital goals and implementing programs to meet those needs.

12.2-4 Meetings
The Medical staff shall meet at least once a month and maintain a permanent record of its proceedings and actions ...

12.4 Description of Functions
12/4-1 Patient Care Evaluation (Quality Improvement)
The duties involved in performing patient care evaluation are:
(a) Adopt specific programs and procedures for the identification and resolution of problems that impact the quality of patient care in order to maintain the desired quality, efficiency, and effectiveness of patient care within the Hospital. The findings and results of these assessment activities shall be reported to the Medical Staff.

(b) Patient care evaluations shall include medical and/or multi-disciplinary studies as well as clinical service studies designed to evaluate the quality and appropriateness of patient care within each clinical service;

(c ) Patient care evaluation shall be performed in accordance with the Hospital's quality assurance plan ...

12.4-6 Pharmacy and Therapeutics
The duties involved in developing and maintaining surveillance over drug utilization policies and practices are to:
(a) Assist in the formulation of the professional policies regarding the evaluation, appraisal, use, safety procedures and all other matters relating to drugs in the Hospital ...

12.4-11 Safety
The Staff member's duties involved in the Hospital's multi-disciplinary safety committee are to:

(a) Participate in the program of staffing, equipping, operating, and maintaining the hospital designed to produce safe characteristics and practices and to eliminate or reduce the extent possible, hazards to patients, Hospital Staff, and visitors ...

(e) The Safety Committee will meet on a quarterly basis ...

Article XIII Meetings

13.1 Annual Staff Meetings

13.1-1 Meeting time
The annual Staff Meeting shall be held at least one (1) day before the end of the Medical Staff year and shall replace the December meeting of the Medical Staff.

13.1-2 Order of Business and Agenda
The order of business at an annual meeting shall be determined by the Chief of Staff. The agenda shall include at least:
(a) Reading and acceptance of the minutes of the last regular and of all special meetings since the last regular meeting;
(b) Administrative reports from the Administrator, the Chief of Staff, and appropriate committee chairman;

(c ) The election of officers and other officers of the Medical Staff when required by these Bylaws ...

(e) Recommendations for maintenance and/or improvement of patient care ...

13.2 Regular Staff Meetings

13.2-1 Meeting Time

The Medical Staff may, by resolution, provide the time for holding regular meetings ... The frequency of such meetings shall be as required by these Bylaws, but shall be at least once a month ...

13.4 Quorum

13.4-1 General Staff Meeting
The presence of a majority of the voting members of the Active Medical Staff at any regular or special meeting shall constitute a quorum for the purpose of amendment to these Bylaws, or shall constitute a quorum for the transaction of all other business. This quorum must be found before any action may be taken, but once found, the business of the meeting may continue and all actions taken thereafter shall be binding even though less than a quorum may be present at a later time in the meeting.

13.4-2 Department and Committee Meetings
A majority of the voting members of a committee, but not less than two members, shall constitute a quorum at any meeting of such committee ...

13.7 Attendance Requirements

13.7.1 Regular Attendance
Each member of a Staff category required to attend meetings under Article IV shall be required to attend:
(a) The Annual Medical Staff meeting.
(b) At least 60 percent of all other Medical Staff meetings duly convened pursuant to these Bylaws; and
(c ) At least 50 percent of all meetings of each committee of which he is a member ...

The surveyor requested the Meeting Minutes of the Medical staff for December 2016 to ensure the election of medical staff members, including Chief of Staff, Vice Chief of Staff and Secretary/Treasurer.

Review of the Meeting minutes of the Medical Staff revealed the last meeting for 2017 was conducted on May 2, 2017.

An interview was conducted on 1/11/8 at 10:08 AM with Employee Identifier (EI) # 1, Administrator, who stated there was no other documentation of Medical Staff meetings for 2017 because, "EI # 11, former Chief of Staff was ineffective." The surveyor asked about EI # 11 and documentation of being the Chief of Staff. EI # 1 stated, "He got ill...not on the schedule since May/June". There was no documentation the Medical Staff elected a replacement Chief of Staff.

Review of the Governing Body Meeting Minutes dated November 21, 2017 revealed documentation that the EI # 1, Administrator introduced EI # 3 as the Chief of Staff. There was no documentation EI # 3 was voted in by the Medical Staff to be the Chief of Staff.

An email response from the facility was received on 1/18/18 related to the Medical Staff Meeting for December 2016, which revealed, "There was no Medical Staff Meeting held December 2016."

There was no documentation of annual meetings of the Medical Staff in December 2016 or 2017 to elect the Medical Staff Officers.

An interview was conducted on 1/19/18 at 9:31 AM with EI # 3, who verified there was no documentation of Medical Staff Meetings since May 2017. EI # 3 stated that he thought the medical staff tries to meet at least every 3 months.

Based on review of the Current Roster of Medical Staff Members 2017-2018, Medical Staff Bylaws/Rules and Regulations, Meeting minutes of the Medical Staff and interviews, it was determined the facility failed to ensure:

1. There was an organized Medical Staff committee to meet the needs of the patients.

2. The Medical Staff committee actively participated in monthly meetings to evaluate the care provided by the physicians for the hospital.

This had the potential to affect all patients served by this Hospital.

Findings include:

Review of the Medical Staff Bylaws and Rules and Regulations of Hill Hospital of Sumter County which were reviewed by the Administrator on 4/4/17, Chairman of the Governing Board on 4/18/17 and Chief of Staff/Assistant Chief of Staff on 4/26/17 revealed:

Article XI Officers
11.1 Officers of the Staff

11.1-1 Identification
The officers of the Staff shall be:
(a) Chief of Staff
(b) Vice Chief of Staff
( c) Secretary/Treasurer

11.1-2 Qualifications

Officers must be members of the Active Staff at a time of nomination and election and must remain members in good standing during their term of office ...

11.1-3 Election
Officers shall be elected at the annual meeting of the Staff in December. Only Staff accorded the prerogative to vote for general Staff officers under Article IV shall be eligible to vote. Voting shall be by ballot. An officer shall be elected upon receiving a majority of the valid votes cast ...

11.1-5 Vacancies in Elected Office
Vacancies in offices, other than those of the Chief of Staff and Vice Chief of Staff shall be filled by the Medical Staff. If there is a vacancy in the office of Chief of Staff, the Vice Staff shall serve out the remaining term. A vacancy in the office of Vice Chief of Staff shall be filled by the Secretary/Treasurer.

11.1-6 Duties of Elected Officers
(a) The Chief of Staff shall serve as the Chief Medical Officer and principal elected official of the Staff. As much, he shall:
(1) Aid in coordinating the activities and concerns of the Hospital administration and of the nursing and other non-physician patient care services with those of the Medical Staff;
(2) Be responsible to the Board, in conjunction with the Medical Staff, for the quality and efficiency of clinical services and professional performances within the Hospital and for the effectiveness of patient care evaluations and the quality assurance functions delegated to the Staff ...
(7) Call, preside at, and be responsible for the agenda of all general meetings of the Medical Staff ...

(8) Serve as a member of the Board of Trustees at the discretion of the Board.

(b) Vice Chief of Staff:
... responsible for the Bylaws and Joint Conference Function. In temporary absence of the Chief of Staff, he shall assume all the duties and have authority of the Chief of Staff. He shall perform such additional duties as may be assigned to him by the Chief of Staff, the Medical Staff or the Board ...

( c) Secretary/Treasurer
... shall be a member of the Medical Staff and a member of all other Staff committees or functions ... duties shall be to:
(1) Give proper notice of all Staff meetings on order of the appropriate authority.
(2) Prepare accurate and complete minutes for all meetings ...

Review of the Current Roster of Medical Staff Members 2017-2018 revealed:

Employee Identifier (EI) # 3 was Chief of Staff
EI # 10 was Emergency Room (ER) Director

There was no documentation of a Vice Chief of Staff or a Secretary/Treasurer.

Review of the Governing Body Meeting Minutes dated November 21, 2017 revealed documentation that the Employee Identifier (EI) # 1, Administrator introduced EI # 3 as the Chief of Staff. There was no documentation EI # 3 was voted in as Chief of Staff by the Medical Staff.

An interview was conducted with EI # 1 on 1/11/18 at 10:25 AM. The surveyor asked how often did EI # 3 come to the hospital and the response was, "...on the schedule 1 to 2 times a month to include 4 shifts per month".

An interview was conducted with EI # 10 on 1/22/18 at 9:55 AM. The surveyor asked what were EI # 10's job responsibilities for the facility and the response was, "I do contract with the ER occasionally. I just work for the hospital and get paid for every hour worked".

The surveyor asked if EI # 10 was the ER Director and the response was, "I was like 3 to 4 years ago. We have been having trouble getting staff for the ER for 1 to 1 1/2 years due to not getting paid".

Based on observations and interviews, it was determined the facility failed to ensure all medications available for patient use were not expired. This had the potential to negatively affect all patient served by this hospital.

Findings include:

A tour of the Emergency Department (ED) was conducted on 1/9/18 at 10:15 AM in the presence of Employee Identifier (EI) # 4, ED Registered Nurse (RN). An observation of the crash cart was conducted and the following was observed:

(2) Epinephrine 1 mg (milligram)/10 ml (milliliter) (1:10,000) expired 11/2017
(1) Epinephrine 1 mg/10 ml (1:10,000) expired 9/2017
(4) Magnesium Sulfate 5 grams (gm) / 10 ml expired 11/2017
(8) phenylephrine hydrochloride (HCL) 10 mg/1 ml expired 11/17
(2) 5% Dextrose 500 ml expired 8/17

Observed located in the Trauma room were the following expired items:

(2) Naloxone HCL 0.4 mg / 1 ml expired 11/1/17
(1) Sodium Chloride (NaCl) intravenous (IV) flush 12 ml - open
(1) 0.9% NaCl (1) liter (L) bottle - opened 6/15/17
(1) 0.9% NaCl (1) L bottle - open (unable to determine the date opened)
(1) Povidone - Iodine 8 fluid ounce (oz) bottle - opened 5/17/17

Observed located in the ED medication closet were the following expired medications:

(1) Tylenol oral suspension expired 6/2017
(1) Robafen expectorant expired 9/2017
(1) Phenytoin suspension 125 mg/5 ml expired 7/2017
(1) Hydroxyzine HCL expired 7/2017
(1) Lidocaine oral/topical viscous 2% expired 3/2015
(1) Actidose with Sorbitol / Activated Charcoal expired 9/2017
(1) package of Sore throat lozenges expired 3/2017
(1) Benzonatate 200 mg expired 1/2017
(4) Furosemide 40 mg/4 ml expired 11/2017
(3) Lidocaine 2% 100 mg/20 ml expired 12/2017
(2) Adenosine 6 mg/2 ml expired 12/2017
(8) Metoprolol Tartrate 5 mg/ 5 ml expired 11/1/2017

An interview was conducted with EI # 4 on 1/9/18 at 10:15 AM during the tour, who verified the above findings

On 1/9/18 at 1:30 PM in the presence of EI # 12, Licensed Practical Nurse (LPN), the surveyors observed located in the after hours pharmacy located near the nursing station the following expired medications:

(2) Piperacillin/Tazobactam 3.375 gm expired 10/2017
(2) Ampicillin 1 gm expired 9/2017
(5) Verapamil HCL 10 mg expired 8/1/2017
(4) Xopenex 1.25 mg expired 12/2017
(10) Pantoprazole 40 mg expired 12/2017
(13) Oxcarbazinephine 150 mg expired 12/2017
(21) Warfarin Sodium 2 mg expired 9/2017
(20) Docusate Sodium 100 mg expired 11/2017
(25) Gabapentin 100 mg expired 11/2017

Located in the crash cart near the nursing station were the following expired medications:

(2) Lidocaine HCL 100 mg (20 mg /1 ml) expired 12/1/2017
(8) phenylephrine HCL 10 mg / 1 ml expired 11/2017
(1) Lidocaine 2 gm / 500 ml expired 11/2017

An interview was conducted with EI # 12 on 1/9/18 at 10:15 AM during the tour, who verified the above findings.

Based on review of facility policy, documentation submitted by the facility related to diversion dates and times, EMS (Emergency Medical Services) Run Report, Registered Nurse (RN) personnel files, Job Descriptions, medical records and interviews with facility staff, it was determined the facility failed:

1. To ensure the emergency department followed it's policy for diversion, in that:

a. There was no documentation the staff notified the local EMS representative.

b. The policy for diversion did not specify the number of hours the facility would update EMS with diversion status.

c. The facility was not on diversion greater than 6 hours in a 24 hour period or received approval from the local on-call EMS representative for diversion greater than 6 hours.

d. The facility conducted an internal review of the diversion, including causative factors and efforts undertaken to avoid the diversion, and submit a written critique to the local EMS office within a 72-hour period.

e. The facility staff failed to follow their policy related to the exceptions to diversion for Patient Indentifer (PI) # 1, a patient who was experiencing a cardiac arrest with EMS requesting assistance to stabilize the patient.

2. To ensure the emergency department was staffed 24 hours a day with nursing personnel who were currently certified in BCLS (Basic Cardiopulmonary Life Support), ACLS (Advanced Cardiac Life Support) and/or PALS (Pediatric Advanced Life Support).

3. To ensure the emergency department had Emergency Department (ED) physicians.

Findings include:

Refer to A 1104, A 1110, and A 1112 for findings.

Based on review of the Current Roster of Medical Staff Members 2017-2018, Medical Staff Bylaws/Rules and Regulations, Meeting minutes of the Medical Staff, facility policy and interviews, it was determined the facility Emergency Department was not under the direction of a Medical Staff member.

This had the potential to affect all patients served by this Hospital.

Findings include:

Facility Policy: Emergency Department "On-Call" List
Reference # 6009
No date

Policy: It is the policy of the Emergency Department to provide timely services and care to all patients accessing the Emergency Department. To assure patients receive care specific to their clinical presentation by a licensed independent practitioner, the Emergency Department maintains an "on-call" roster pf primary and specialty care practitioners.

Procedure:

...Assessment of the provisional staff member's care, treatment and service provided to Emergency Department patients will be conducted by either the chairperson of the provisional staff member's department or the Emergency Department Medical Director as a component of the provisional staff member's proctoring program.

Review of the Medical Staff Bylaws and Rules and Regulations of Hill Hospital of Sumter County which were reviewed by the Administrator on 4/4/17, Chairman of the Governing Board on 4/18/17 and Chief of Staff /Assistant Chief of Staff on 4/26/17 revealed:

Preamble

...Whereas, its purpose is to serve as an acute care general hospital providing patient care, education and research; and

Whereas, it is recognized that one of the aims and goals of the Medical Staff is to strive for optimal achievable quality patient care in the Hospital, that the Medical Staff must cooperate with and is subject to the ultimate authority of the Governing Board, and that the cooperative efforts of the Medical Staff, Management, and the Governing Board are necessary to fulfill the Hospital's aims and goals in the Hospital...

Article II Purposes and Responsibilities

2.1 Purposes

The purpose of the Medical Staff are:

2.1-1 To ensure that all patients admitted to or treated in any of the facilities, departments, or services of the Hospital shall receive optimal achievable quality patient care commensurate with available resources...

Article XI Officers
11.1 Officers of the Staff

11.1-1 Identification
The officers of the Staff shall be:
(a) Chief of Staff
(b) Vice Chief of Staff
( c) Secretary/Treasurer

11.1-6 Duties of Elected Officers
(a) The Chief of Staff shall serve as the Chief Medical Officer and principal elected official of the Staff. As much, he shall:
(1) Aid in coordinating the activities and concerns of the Hospital administration and of the nursing and other non-physician patient care services with those of the Medical Staff;
(2) Be responsible to the Board, in conjunction with the Medical Staff, for the quality and efficiency of clinical services and professional performances within the Hospital and for the effectiveness of patient care evaluations and the quality assurance functions delegated to the Staff ...
(7) Call, preside at, and be responsible for the agenda of all general meetings of the Medical Staff ...

(b) Vice Chief of Staff:
... responsible for the Bylaws and Joint Conference Function. In temporary absence of the Chief of Staff, he shall assume all the duties and have authority of the Chief of Staff. He shall perform such additional duties as may be assigned to him by the Chief of Staff, the Medical Staff or the Board ...

Review of the Current Roster of Medical Staff Members 2017-2018 revealed:

Employee Identifier (EI) # 3 was Chief of Staff
EI # 10 was Emergency Room (ER) Director

Review of the Governing Body Meeting Minutes dated November 21, 2017 revealed documentation that the Employee Identifier (EI) # 1, Administrator introduced EI # 3 as the Chief of Staff. There was no documentation EI # 3 was voted in as Chief of Staff by the Medical Staff.

An interview was conducted with EI # 1, Administrator on 1/11/18 at 10:25 AM. The surveyor asked how often did EI # 3 comes to the hospital and the response was, "...on the schedule 1 to 2 times a month to include 4 shifts per month".

An interview was conducted with EI # 10 on 1/22/18 at 9:55 AM. The surveyor asked what were EI # 10's job responsibilities for the facility and the response was, "I do contract with the ER occasionally. I just work for (hospital) and get paid for every hour worked".

The surveyor asked if EI # 10 was the ER Director and the response was, "I was like 3 to 4 years ago. We have been having trouble getting staff for the ER for 1 to 1 1/2 years due to not getting paid".

Based on review of facility policy, documentation submitted by the facility related to diversion dates and times, EMS (Emergency Medical Services) Run Report and interviews with facility staff, it was determined the facility failed to ensure the Emergency Department (ED) followed it's policy for diversion, in that:

1. There was no documentation the staff notified the local EMS representative.

2. The policy for diversion did not specify the number of hours the facility would update EMS with diversion status.

3. The facility was on diversion greater than 6 hours in a 24 hour period or received approval from the local on-call EMS representative for diversion greater than 6 hours.

4. The facility conducted an internal review of the diversion, including causative factors and efforts undertaken to avoid the diversion, and submit a written critique to the local EMS office within a 72-hour period.

5. The facility staff failed to follow their policy related to the exceptions to diversion for Patient Indentifer (PI) # 1, a patient who was experiencing a cardiac arrest with EMS requesting assistance to stabilize the patient.

This affected Patient Identifier (PI) # 1 and has the potential to negatively affect all patients who present to this facility seeking emergency medical treatment.

Findings include:

Facility Policy
Reference # 6008
Emergency Department Diversion

Policy: It is the policy of this hospital to divert patients from the Emergency Department only when certain pre-established conditions exist that negatively and profoundly impact this organization's ability to provide safe patient care. To assure that diversion is implemented only when necessary, a list of diversion criteria, developed and approved by the Medical Staff and Governing Body of this hospital, has been established for use by Emergency Department personnel.

Procedure:
Ambulance diversion by basic Emergency Department shall only occur as the result of circumstances which result in a disruption of essential hospital services ...

Diversion approval must be obtained prior to requesting ambulance diversion. Approval must be obtained from the following individuals:

Emergency Department Medical Director or his/her designee (must be a licensed independent practitioner member of the medical staff)

Emergency Department Nurse Manager/Supervisor or his/her designee

CEO (Chief Executive Officer) or his/her designee

The Emergency Department Nurse Manager/Supervisor will contact the local EMS (Emergency Medical Services) office and report the diversion status. The report from the ED must include:

The reason for requesting diversion status

The name of the senior administrative officer at the hospital approving the diversion

The expected duration of the diversion

The hospital requesting diversion must update the local EMS office ___ hours regarding its diversion status (time limit specified by state DHHS (Department of Health and Human Services) and local EMS office).

The hospital may be on diversion status for no more than six (6) hours in any 24-hour period. Any exceptions require the approval of the local on-call EMS representative. The hospital will come off of diversion status as soon as possible once the situation(s) causing diversion have been resolved.

The hospital will follow requirements of the local EMS agency for terminating diversion status.

The hospital will conduct an internal review of the diversion, including causative factors and efforts undertaken to avoid the diversion, and submit a written critique to the local EMS office within 72-hour period. The critique must include:
Facility name
Date of diversion
Reason for diversion
Times on and off diversion
Name of hospital administrator authorizing diversion
Summary of attempts to mitigate conditions requiring diversion

Any identified problems associated with patient care for diverted patients will be submitted to the local EMS on an Unusual Occurrence Report (provided by the EMS office) form within two (2) weeks following identification of the problem.

The following patient conditions are exceptions to diversion status and cannot be diverted to another care provider:

Obstetric patients

Patients with uncontrollable conditions/problems (unmanageable airway, unstable cardiac condition, uncontrolled hemorrhage, full cardiopulmonary arrest, etc.) ...

Unstable patients who, in the judgment of the paramedic, may be subjected to increased risk by being transported beyond a hospital on diversion. In this instance, the patient should be transported to the closest, most appropriate facility, regardless of the diversion status.


1. Review of the EMS Run Report dated 12/25/17 for PI # 1 revealed, PI # 1's chief complaint was difficulty breathing/shortness of breath. The patient experienced cardiac arrest after EMS arrival at the scene. The patient's cardiac rhythm was (PEA) pulseless electrical activity. The EMS initiated cardiopulmonary resuscitation (CPR) and the patient's pulse returned. EMS documented, "family states... (patient) was discharged from (hospital) a couple of days ago for atrial fib (fibrillation). Radial pulse rapid and weak. Pt (patient) in living room on... knees. Pt assisted to the stretcher at the bottom of about 10 steps of a mobile home. While rolling to the truck pt became unresponsive. No pulse. CPR started. EKG (electrocardiogram) PEA rate of 24. Oral airway BVM (bag valve mask) with high flow O2 (oxygen). IV (intravenous) NS (normal saline)... left hand. EPI (epinephrine) given every 5 minutes. ET (endotracheal tube) attempted twice WO (without) success. Starting transport to Hill Hospital. Hill on diversion and wouldn't accept the patient. Med (medical) control... contacted and discussed... Picked up additional EMT (Emergency Medical Technician) and transported to (Hospital Name - 32 miles from Hill Hospital).


An interview was conducted on 1/9/18 at 8:00 AM with Employee Identifier (EI) # 8 Emergency Department (ED) Registered Nurse (RN). The surveyor asked, "How often the ED went on diversion?" EI # 8 stated, "Not that often. Usually it's until a physician comes in. Maybe, 12 hours." She stated that the facility was on diversion all night, "last night." When questioned who is contacted if the facility goes on diversion, EI # 8 stated that usually when she comes in, everyone has been notified. She stated that once the doctor comes in, she contacts the local Fire Departments (FD), Police Departments (PD), 911 and ambulance service. The surveyors asked if there is a log related to being on diversion and contacting the local FD, PD, 911 and ambulance. EI # 8 stated there is a book with phone numbers. When questioned if the calls are documented, EI # 8 stated, "No."

The surveyors asked what reasons the facility goes on diversion, EI # 8 stated, "Because, we do not have a doctor." The surveyors asked, "What does diversion mean to you?" EI # 8 stated, "Here is because we don't have a doctor. We do not have the capability to take care of the patient."

The surveyor asked what was the process for care for a patient if they present to the ED while on diversion? EI # 8 stated, "When they come in, we go out and talk with them. We tell them we do not have a physician and give them information related to other area hospitals. I call EI # 3, Chief of Staff and he instructs the staff on what to do with the patient.


When questioned if a patient had presented to the ED while the facility was on diversion, EI # 8 stated, "Yes." She stated that she followed the above process for patients that presented to the ED while on diversion.


The surveyors asked about PI # 1. She stated the ambulance called and she told them that the hospital did not have a physician. She stated the ambulance informed her that they had to come to the hospital. EI # 8 stated she called EI # 3, Chief of Staff who stated the ambulance needed to send the patient to (Name of city, which is 32 miles from the hospital). She stated she called the ambulance and told them the hospital was unable to support ACLS because there was no physician in the hospital. She stated she could help with CPR, but was unable to perform ACLS without a physician. She stated that she set up the trauma room. EI # 8 stated the ambulance stayed out in the parking lot. Another ambulance pulled up, two staff members got out and came into the ED. I informed them the ambulance staff and patient were still in the truck (ambulance). They walked out of the ED, got into the other ambulance and left the hospital.

An interview was conducted on 1/10/18 at 12:30 PM with EI # 6 ED, RN. The surveyor asked, "How often the ED went on diversion?" EI # 6 stated that the facility has had problems with getting physician coverage in the ED some times during this past year at various times. When questioned how long the facility has been on diversion, EI # 6 stated usually not longer than a day.


The surveyors asked who is contacted when the facility goes on diversion, EI # 6 stated the ambulance services are called. The surveyors asked what is the reason for the facility to go on diversion. EI # 6 stated that it's because there is no doctor available. When questioned what diversion meant to her, EI # 6 stated, "We don't have the doctor here and the ambulance can't come in because we can't treat the patient without orders."


The surveyors asked what is the process when a patient presents to the ED while on diversion. EI # 6 stated that she immediately tells them that we do not have a doctor. I bring them in to check vital signs and do an assessment. I find out it they need to see someone else or if it's an emergency. Some say this is not acceptable and that they are going to report it. When questioned where vital signs are documented, EI # 6 replied, "Most people do not want to be assessed and they will come back in the morning."

The surveyor asked if anyone has ever come to the ED while on diversion. EI # 6 stated, "No, never with me." The surveyor then asked if there was a log of patients who present to the ED while on diversion. EI # 6 stated, "No. The staff fills out the triage sheets."


An interview was conducted on 1/10/18 at 1:40 PM with EI # 5 ED RN. The surveyor asked, "How often the ED went on diversion?" EI # 5 stated that she was unable to recall a time when the ED was on diversion, maybe, once that she could remember. When questioned about the reason the ED was on diversion, EI # 5 stated, it was because the physician may have left early and/or the ED physician was going to be late arriving at the hospital.

An interview was conducted on 1/11/18 at 9:35 AM with EI # 2 Director of Nursing (DON). During this interview, the surveyors asked who was the EMS representative? EI # 2 was unsure. The surveyors asked what is her definition of diversion? EI # 2 stated, "Referring patients/ diverting patients to another place because we do not have everything to take care of the patient." She also stated, "Patients came in while we were on diversion and we referred them to the clinic because we don't have a doctor."

The surveyor asked what criteria did the diversion fall under? EI # 2 stated, "Inadequate/overtaxed staff. Specific type things we do not have the ability to perform, like, testing services or people we are unable to provide care." She stated, "I think we can go on diversion because we do not have physician coverage in the ED."

The surveyors asked what measures did the hospital perform to resolve the condition that caused diversion? EI # 2 stated, "EI # 1 Administrator calls, begs and pleads with doctors to stay or to come in. I know she has called as I've heard her on the phone at times."

The surveyors asked who approved the diversion? EI # 2 stated, EI # 1. She stated, "I know she has called and told us that we need to be on diversion."


The surveyor asked what did the ED report to the local EMS office? EI # 2 stated that the facility calls the local EMS, 911 operator, ambulance services and local FDs and PDs. When questioned if this was documented anywhere, EI # 2 stated that the facility tells them all the information, but it is not documented.

The surveyors asked how often the facility updated the local EMS office regarding its diversion status? EI # 2 stated, "At the end of diversion we contact them." The surveyors asked what was the longest time period the ED remained on diversion. EI # 2 stated that she remembered 6 pm to 6 am. The surveyors pointed out to EI # 2 that the hospital had been on diversion this week for 36 hours, which EI # 2 confirmed.

The surveyor asked how are internal reviews of diversions conducted. EI # 2 stated they are not done in a formal fashion. The surveyor asked are written critiques submitted to the local EMS office within 72 hours and the answer was, "No."


The surveyors asked what is the plan to ensure you have provider coverage in the ED. EI # 2 stated, "I don't know. I guess EI # 1 (Administrator) is going to keep trying to contact providers to provide coverage."

An interview was conducted on 1/16/18 at 8:37 AM with the owner of the ambulance service. The surveyor asked if Hill Hospital called the ambulance services to inform them they are on diversion. The response was, "No, not usually. The ambulance crews find out when they are calling report to the hospital and the ambulance crew needs to take the patient somewhere else.



20228

The surveyor requested the date and times the facility went on diversion beginning September 1, 2017 to current on 1/9/18 at 11:00 AM. EI # 9, Quality Manager submitted an hand written sheet on 1/9/18 at 12:00 PM with jumbled up dates and no documentation of the diversion times.

The surveyor requested the dates with specific times from 9/1/17 to current. EI # 9 submitted a log that included the following days and times the hospital was on diversion because of no physician in the facility:

9/1/17 = 6 AM to 6 AM, which was 24 hours
9/5/17 = 6 AM to 6 AM
9/6/17 = 6 AM to 6 PM, which was 36 hours
9/19/17 = 6 AM to 6 AM
9/20/17 = 6 AM to 6 AM
9/21/17 = 6 AM to 6 PM, which was 60 hours
9/26/17 = 6 AM to 6 AM
9/27/17 = 6 AM to 6 PM, which was 36 hours
10/4/17 = 6 AM to 6 PM, which was 12 hours
10/7/17 = 1 PM to 6 AM, which was 17 hours
10/18/17 = 6 AM to 6 AM
10/19/17 = 6 AM to 6 AM, which was 48 hours
10/21/17 6 AM to 6 PM, which was 12 hours
11/1/17 = 6 AM to 6 PM, which was 12 hours
11/2/17 6 PM to 6 AM
11/3/17 = 6 AM to 6 AM
11/4/17 = 6 AM to 6 AM
11/5/17 = 6 AM to 6 AM, which was 84 hours
11/9/17 = 6 PM to 6 AM
11/10/17 = 6 AM to 6 AM, which was 36 hours
12/24/17 = 6 AM to 6 AM
12/25/17 = 6 AM to 6 AM, which was 24 hours
1/2/18 = 6 AM to 6 AM, which was 24 hours
1/9/18 = 6 AM to 6 AM
1/10/18 = 6 AM to 6 PM, which was 36 hours

It was determined through review of documentation located in an envelope labeled "N.P.A." (No Physician Available) and medical record review, there was no physician available in the Emergency Department (ED) on the following dates: 10/17/17, 11/11/17, 11/24/17, 12/26/17, 12/27/17 and 12/31/17. The documentation in the envelope labeled N.P.A was triage sheets and nurse's note for Patient Identifier (PI) # 5, PI # 4, PI # 28, PI # 33, PI # 34, PI # 35, PI # 36, PI # 37, PI # 38, PI # 39 and PI # 40.

A review of the above diversion dates and times submitted to the surveyors revealed no documentation the facility was on diversion on 10/17/17, 11/11/17, 11/24/17, 12/26/17, 12/27/17 and 12/31/17.

An interview was conducted on 1/9/18 at 10:15 AM with EI # 4, ED RN. The surveyor asked if there was a physician in the ED at the present time. EI # 4 stated, "Right now I do not have an ED physician." The surveyor asked what the staff do when there is no ED physician. EI # 4 stated, "I will call the ambulance and have them take the patient to another hospital. If an ambulance calls I tell them we are on diversion and to take the patient some where else. We call the EMTs when we know we are on diversion." The survey then asked to see documentation of when the EMTs were notified the hospital was on diversion. EI # 4 stated there was none.

An interview was conducted on 1/9/18 at 1:00 PM with EI # 1, Administrator. The surveyor asked the name of the physician who was over the ED. EI # 1 stated that it should be EI # 10, Emergency Room Director. EI # 1 left the room to go ensure who was the Emergency Room Director. EI # 1 returned to the room and stated it was EI # 10.

An interview was conducted with EI # 7, RN on 1/10/18 at 11:00 AM. The surveyor asked what the staff were suppose to do if there was no physician in the ED. EI # 7 stated, " If we go on diversion, we call the ambulances in the area and the police". The surveyor asked what was the staff to do if a patient walked in to the ED. EI # 7 stated, " Assess the patient and call the Chief of Staff ". The surveyor asked where the staff document the assessment and the response was, " The triage sheet". The surveyor requested documentation when the staff notified the ambulances and the police and the response was, " There is no book to document diversions that I know of".

An interview was conducted on 1/11/18 at 10:08 AM with EI # 1, Administrator. The surveyor asked who has the authority to approve the hospital going on diversion? EI # 1 stated the administrator or the Medical Director can give approval. The surveyor asked where and how the decision to go on diversion was documented. EI # 1 stated, "The person that makes that particular call - it should be logged". The surveyor asked what was the longest time period the ED remained on diversion and the response was, "We have gone 24 to 36 hours". The surveyor asked if EI # 1 was aware the policy included the following, "The hospital may be on diversion status for no more than six (6) hours in any 24-hour period" and the response was, "No".

The surveyor asked how often the EMS office is updated regarding the diversion. EI # 1 stated, "If there is no doctor they will let EMS know we are on diversion until further notice and contact them within 30 minutes to 1 hour before the diversion is over".

Based on review of facility policy, EMS (Emergency Medical Services) Run Report, Registered Nurse (RN) personnel files, Job Description and interviews with facility staff, it was determined the hospital failed to ensure the emergency department was staffed 24 hours a day with nursing personnel who were currently certified in BCLS (Basic Cardiopulmonary Life Support), ACLS (Advanced Cardiac Life Support) and/or PALS (Pediatric Advanced Life Support).

This affected Patient Identifier # 1 and has the potential to negatively affect all patients who seen at this facility.

Findings include:

Facility Policy
Reference #8025
Subject: Staffing - General
Department: Emergency Department

Policy: The professional accountability for the provision of nursing care to patients in the hospital is addressed in job descriptions and further defined in the following staffing policy statement ...

Each unit or area where patient care is provided will have a staffing plan to provide for a sufficient number of professional nursing staff (RN {Registered Nurse}, LPN/LVNs {Licensed Practical Nurse/Licensed Vocational Nurse, CNAs {Certified Nurse Assistant}) and professional ancillary staff (registered physical therapists, registered respiratory therapists, etc.) to carry out at least the following activities:

Prescription of care, treatment and services for patients based on:
Assessment data and other relevant information
Identified patient needs/problems
Appropriate healthcare interventions as specified in standards, policies and procedures, protocols or as determined by professional judgment
The patient's response to healthcare interventions ...

The Emergency Department will be staffed with licensed personal 24 hours per day as follows:
A minimum of ____ registered nurses who are ACLS (Advanced cardiac Life support) certified with Emergency Department experience per shift.

Appropriate personnel to meet quality patient care per shift:
____ RNs
____ LPNs/LVNs
____ Emergency Department Technicians
____ Transporters
____ Unit Secretaries
____ Board-certified Emergency Department physicians ...
(Note: All of the above personnel categories were blank and included no facility identified quantity of staff required to provide quality patient care, including the Board-certified Emergency Department physicians.)

Review of the Position Description for Job Title: Emergency department Registered Nurse I revealed Regulatory Requirements included, " ... Current BCLS (Basic Cardiopulmonary Life Support, ACLS Certified within six (6) months of hire ... PALS within one (1) year of hire ..."


Review of the Manager's Meeting minutes revealed on 10/31/17 there was a hand written note, " ...ACLS/BLS (Basic life support) - (Name) ..." There was no other documentation of what this handwritten note indicated and no further documentation ACLS/PALS (Pediatric Advanced Life Support) was discussed.

Review of 12 of 13 RN personnel files hired between 1987 and 2014 revealed ACLS certification had expired in November 2017


Review of the EMS Run Report for dated 12/25/17 for PI # 1 revealed, PI # 1's chief complaint was difficulty breathing/shortness of breath. The patient experienced cardiac arrest after EMS arrival at the scene. The patient's cardiac rhythm was (PEA) pulseless electrical activity. The EMS initiated cardiopulmonary resuscitation (CPR) and the patient's pulse returned. EMS documented, "family states... (patient) was discharged from (hospital) a couple of days ago for atrial fib (fibrillation). Radial pulse rapid and weak. Pt (patient) in living room on... knees. Pt assisted to the stretcher at the bottom of about 10 steps of a mobile home. While rolling to the truck pt became unresponsive. No pulse. CPR started. EKG (electrocardiogram) PEA rate of 24. Oral airway BVM (bag valve mask) with high flow O2 (oxygen). IV (intravenous) NS (normal saline)... left hand. EPI (epinephrine) given every 5 minutes. ET (endotracheal tube) attempted twice WO (without) success. Starting transport to Hill Hospital. Hill on diversion and wouldn't accept the patient. Med (medical) control... contacted and discussed... Picked up additional EMT (Emergency Medical Technician) and transports to (Hospital Name - 32 miles from Hill Hospital).


An interview was conducted on 1/9/18 at 8:00 AM with Employee Identifier (EI) # 8 Emergency Department (ED) Registered Nurse (RN). The surveyors asked about Patient Identifier (PI) # 1. She stated the ambulance called and she told them that the hospital did not have a physician. She stated the ambulance informed her that they had to come to the hospital. EI # 8 stated she called EI # 3, Chief of Staff who stated the ambulance needed to send the patient to (Name of city, which is 32 miles from the hospital). She stated she called the ambulance and told them the hospital was unable to support ACLS because there was no physician in the hospital. She stated she could help with CPR, but was unable to perform ACLS without a physician. She stated that she set up the trauma room. EI # 8 stated the ambulance stayed out in the parking lot. Another ambulance pulled up, two staff members got out and came into the ED. I informed them the ambulance staff and patient were still in the truck (ambulance). They walked out of the ED, got into the other ambulance and left the hospital.

An interview was conducted on 1/11/18 at 9:35 AM with EI # 2, Director of Nursing (DON) who stated she was aware that ACLS/PALS was going to expire. EI # 2 stated she had tried to contact the person to get them to recertify the staff, but as of Christmas, she had not been able to contact someone to recertify the staff. She stated that she had actually forgotten about it until the incident when Patient Identifier (PI) # 1 was brought to the Emergency Department by Emergency Medical Services (EMS) on 12/25/17 and staff were not comfortable performing ACLS without a physician present. EI # 2 stated there was no documentation she had attempted to contact the trainer for ACLS/PALS again.

Based on review of facility policy, hospital's documentation of diversion dates and times, EMS (Emergency Medical Services) Run Report, medical record and interviews with staff, it was determined the facility failed to ensure the emergency department had Emergency Department (ED) physicians.

This affected Patient Identifier (PI) # 1, PI # 2 and had the potential to negatively affect all patients who present to the ED requiring emergency care.

Findings include:

Facility Policy
Reference #8025
Subject: Staffing - General
Department: Emergency Department

Policy: The professional accountability for the provision of nursing care to patients in the hospital is addressed in job descriptions and further defined in the following staffing policy statement ...

Each unit or area where patient care is provided will have a staffing plan to provide for a sufficient number of professional nursing staff (RN) Registered Nurse, LPN/LVNs (Licensed Practical Nurse/Licensed Vocational Nurse)... to carry out at least the following activities:

Prescription of care, treatment and services for patients based on:
Assessment data and other relevant information
Identified patient needs/problems
Appropriate healthcare interventions as specified in standards, policies and procedures, protocols or as determined by professional judgment
The patient's response to healthcare interventions ...

The Emergency Department will be staffed with licensed personal 24 hours per day as follows:
A minimum of ____ registered nurses who are ACLS (Advanced cardiac Life support) certified with Emergency Department experience per shift.

Appropriate personnel to meet quality patient care per shift:
____ Board-certified Emergency Department physicians ...

(Note: The quantity of required Board-certified Emergency Department physicians to provide quality patient care was blank.)

The survey requested the date and times the facility went on diversion beginning September 1, 2017 to current on 1/9/18 at 11:00 AM. EI # 9, Quality Manager submitted an hand written sheet on 1/9/18 at 12:00 PM with jumbled up dates and no documentation of the diversion times.

The surveyor requested the dates with specific times from 9/1/17 to current. EI # 9 submitted a log that included the following days and times the hospital was on diversion because of no physician in the facility:

9/1/17 = 6 AM to 6 AM, which was 24 hours
9/5/17 = 6 AM to 6 AM
9/6/17 = 6 AM to 6 PM, which was 36 hours
9/19/17 = 6 AM to 6 AM
9/20/17 = 6 AM to 6 AM
9/21/17 = 6 AM to 6 PM, which was 60 hours
9/26/17 = 6 AM to 6 AM
9/27/17 = 6 AM to 6 PM, which was 36 hours
10/4/17 = 6 AM to 6 PM, which was 12 hours
10/7/17 = 1 PM to 6 AM, which was 17 hours
10/18/17 = 6 AM to 6 AM
10/19/17 = 6 AM to 6 AM, which was 48 hours
10/21/17 6 AM to 6 PM, which was 12 hours
11/1/17 = 6 AM to 6 PM, which was 12 hours
11/2/17 6 PM to 6 AM
11/3/17 = 6 AM to 6 AM
11/4/17 = 6 AM to 6 AM
11/5/17 = 6 AM to 6 AM, which was 84 hours
11/9/17 = 6 PM to 6 AM
11/10/17 = 6 AM to 6 AM, which was 36 hours
12/24/17 = 6 AM to 6 AM
12/25/17 = 6 AM to 6 AM, which was 24 hours
1/2/18 = 6 AM to 6 AM, which was 24 hours
1/9/18 = 6 AM to 6 AM
1/10/18 = 6 AM to 6 PM, which was 36 hours

1. Review of the EMS Run Report for dated 9/1/17 for PI # 2 revealed the chief complaint was Major Trauma to the head, musculoskeletal system with bleeding. EMS documented the patient was unresponsive, skin color was pale, cool and moist. There patient's peripheral pulses were strong and the patient's blood pressure was 60/systolic via carotid pulse palpation. The patient had deformities to bilateral upper and lower extremities. EMS documented the patient was found entangled under a steel pipe barrier and shrubs. Patient is driver of motorcycle that was thrown approximately thirty (30) feet... is unresponsive... had weak carotid pulse, shallow respirations at approximately 10 per minute. Deformity was noted to all extremities. Cardiac monitor shows normal sinus rhythm... held manual C (cervical) spine immobilization and placed a C collar on patient. The barrier was then lifted off of the patient and patient was placed on back board in a supine position. Once patient was in a supine position an avulsion was noted to... right shoulder and left knee. Placed patient on Oxygen at 15 liters per minute. Secured patient to stretcher with straps, securing... head last with a head immobilizer. When in ambulance attempting IV (intravenous) access patient went into asystole and cardiac arrest. Began CPR at a rate of 30 compressions to two ventilations with a bag valve mask on 15 liters per minute of Oxygen. While ventilating patient blood began to come from... airway. Suctioned patient's airway and ... was then intubated with a 7.5 ET tube... Chest rise and fall was noted with ventilation, bilateral breath sounds were auscultated, and condensation was noted in the tube. Diverted to Hill Hospital due to patient being in cardiac arrest. Transported emergency to Hill Hospital ER (Emergency Room). Paitne left I bed with rails up and bed in lowered position and locked. Verbal report given and patient care turned over to staff present... Patient report and care released to (Name of Flight Crew - air ambulance crew member)... Upon arrival at Hill Hospital ER nurse staff states that there was not a doctor on staff. During report call to the ER this was not advised. Contacted online medical control (physician's name) and advised of patient status and that Hill Hospital did not have a doctor. (Medical control physician) advised that the ER staff had to assume care and stabilize the patient before (he/she) could be transported away from the hospital. At this time (air ambulance) transport services arrived in the ER and began to assume care for the patient. During the time (air ambulance crew) was providing patient care they contacted their medical control doctor (Physican's name) and stated that their med (medical) control advised to discontinue resuscitative efforts. (EMS - medical control physician) was contacted again and advised of what (air ambulance crew) advised and he was in agreement to stop resuscitative efforts...

Review the Transport Medical Record of the air ambulance dated 9/1/17 revealed the air ambulance arrived at the scene at 9:46 PM, "... Pt is a 25 yo (year old)... found lying fully spinal immobilized on hospital bed at charted location. Pt came... via ambulance after... was involved in motorcycle collision vs (versus) tree line. EMS reports that pt was breathing and moaning when they loaded... into their ambulance but quickly decline into arrest shortly afterwards. EMS transported pt to Hill Hospital, Alabama without the knowledge that the facility did not have a physician working in the hospital tonight. On arrival nursing staff assisted EMS with trauma code. Tx (treatment) PTA (prior to arrival) includes CPR, spinal immobilization, and multiple intubation and IV attempts by EMS and IV attempts by ED (Emergency Department) staff..."

At 9:49 PM, the air ambulance crew member documented, "... Advised there is no MD or NP (Nurse Practitioner) in the hospital... EMS reports pt has been in asystole for over 30 min. with CPR in progress..."

"... Treatments, Interventions and Assessments... at 9:50 PM - Airway... Assessment reveals: Failure to Oxygenate, Failure to Protect Airway, Failure to Ventilate... Pre-oxygenated via 15 lpm (liters per minute). Patient prepared for oral intubation. Procedure performed by (Air ambulance crew member)... ET (endotracheal) tube - cuffed 7.5 placed... Invasive lines... Gauge 45 mm (milli-meters) EZ - IO (intraosseous) placed in left humerus Secured... blood return... infuses well... Bolus of 500 ml (milli-liters) NS (normal saline)..."

Review of the Transport Medical Record dated 9/1/17 revealed the patient's physical examination as follows: "... Unconscious, Unresponsive... Pupils fixed and dilated... no movement... Reflexes: Gag absent, Non-reactive. Sensory: Severe or total loss... Skin... pale. Peripheral temperature: Cool, Central temperature: warm... diaphoretic. Capillary refill: more than 2 seconds... Eyes: Left pupil dilated, Pupils non-reactive, Right pupil dilated... Throat: Intact palate Noted bleeding to mouth with missing teeth... Breathing: Apneic. Assisted. Breath sounds: diminished, left decreased, right decrease... Cardiac... Monitored rhythm: Asystole. Abrasion located chest, left chest... Extremities... Laceration located leg - large open laceration to left upper leg. Which was reported to have been bleeding profusely by EMS but has stopped... Noted dressing applied by EMS PTA... Shoulder - Open wound to right shoulder with no bleeding noted..."

Further review of the Transport Medical Record dated 9/1/17 revealed Epinephrine 1 mg (milli-gram) was administered at 9:52 PM and 9:57 PM. On 9/1/17 at 10:01 PM, the air ambulance crew documented having contacted, "MS (Mississippi) MEDCOM" and spoke with (Physician's name). Advised of pt condition with 30+ min (minutes) of CPR with trauma arrest. Pt pronounced at 10:01 PM..."

The air ambulance crew documented after the patient was pronounced dead by online medcontrol physician, the body was left in the care of the hospital staff and county sheriff.

Review of the medical record from Hill Hospital Emergency Department (ED) revealed the patient arrived at the facility on 9/1/17 at 9:50 PM via ambulance in cardiopulmonary arrest. The RN documented the patient had obvious fractures to left arm, right ankle/foot, left knee, fracture to the chin. The patient was on a cardiac monitor with O2 at 15 liters non-rebreather mask. The patient was brought in by ambulance and CPR was in progress, vital signs were absent and patient was asystole. The RN documented at 9:53 PM the patient was intubated and an intraosseous (IO) access was placed by air ambulance crew member and at 9:55 PM, 1 milligram (mg) Epinephrine was administered by air ambulance crew member via IO. At 10:01 PM, the patient was pronounced dead by (air ambulance crew physician). Review of the Code II Record dated 9/1/17 at 9:40 PM revealed the team members documented in the code were (1) RN and (1) Licensed Practical Nurse (LPN). There was no documentation of "Physicians in attendance." Compressions were documented as being performed by (Air ambulance EMTs).

There was no documentation the RN and/or LPN actively participated in the resuscitative measures that were attempted for PI # 2 and there was no documentation a physician was present.

An interview was conducted on 1/10/18 at 1:40 PM with EI # 5, ED RN. The surveyor asked, "How often the ED went on diversion?" EI # 5 stated that she was unable to recall a time when the ED was on diversion, maybe, once that she could remember. When questioned about the reason the ED was on diversion, EI # 5 stated, it was because the physician may have left early and/or the ED physician was going to be late arriving at the hospital.

EI # 5 confirmed she was present the night PI # 2 was brought to the ED while the facility was on diversion because there was no ED physician. She stated the ambulance knew the facility was on diversion and the patient was to be transported to another facility via air ambulance. The staff had gone to the front parking lot to make sure all of the cars had been moved out of the area so the helicopter could land. When we got back to the ED, the ambulance crew had brought the patient into the ED and was performing CPR (cardiopulmonary resuscitation). She stated that air ambulance crew came into the ED and took over the code (CPR). She stated the patient was dead on arrival to the ED.

2. Review of the EMS Run Report for dated 12/25/17 for PI # 1 revealed, PI # 1's chief complaint was difficulty breathing/shortness of breath. The patient experienced cardiac arrest after EMS arrival at the scene. The patient's cardiac rhythm was (PEA) pulseless electrical activity. The EMS initiated CPR and the patient's pulse returned. EMS documented, "family states... (patient) was discharged from (hospital) a couple of days ago for atrial fib (fibrillation). Radial pulse rapid and weak. Pt (patient) in living room on... knees. Pt assisted to the stretcher at the bottom of about 10 steps of a mobile home. While rolling to the truck pt became unresponsive. No pulse. CPR started. EKG (electrocardiogram) PEA rate of 24. Oral airway BVM (bag valve mask) with high flow O2 (oxygen). IV NS (normal saline)... left hand. EPI (epinephrine) given every 5 minutes. ET (endotracheal tube) attempted twice WO (without) success. Starting transport to Hill Hospital. Hill on diversion and wouldn't accept the patient. Med (medical) control... contacted and discussed... Picked up additional EMT (Emergency Medical Technician) and transported to (Hospital Name - 32 miles from Hill Hospital).


An interview was conducted on 1/9/18 at 8:00 AM with Employee Identifier (EI) # 8 ED Registered Nurse (RN). The surveyors asked about PI # 1. She stated the ambulance called and she told them that the hospital did not have a physician. She stated the ambulance informed her that they had to come to the hospital. EI # 8 stated she called EI # 3, Chief of Staff who stated the ambulance needed to send the patient to (Name of city, which is 32 miles from the hospital). She stated she called the ambulance and told them the hospital was unable to support ACLS because there was no physician in the hospital. She stated she could help with CPR, but was unable to perform ACLS without a physician. She stated that she set up the trauma room. EI # 8 stated the ambulance stayed out in the parking lot. Another ambulance pulled up, two staff members got out and came into the ED. I informed them the ambulance staff and patient were still in the truck (ambulance). They walked out of the ED, got into the other ambulance and left the hospital.

On 1/16/18 at 8:18 AM an interview was conducted with EMS paramedic. The surveyor asked about the events regarding PI # 1. The paramedic stated the nurse came out to the ambulance and stated the hospital did not have a doctor and the staff were not comfortable giving ACLS drugs. The surveyor asked if the staff at the hospital assisted you in any way. The Paramedic said, "Negative. She stood at the side door of the ambulance." The surveyor asked if there was a physician, nurse practitioner or physician's assistant at the facility. The paramedic again stated, "Negative."

The paramedic stated they (ambulance) were about 3 miles from the hospital and the patient went into cardiac arrest in front of us. He stated he worked the code. The ambulance driver stated the hospital was not taking them. He stated he asked the driver why? He stated the driver said there's no doctor, nurse practitioner, nothing. At that time, they were sitting in the hospital's parking lot. He stated he called the EMS Medical Control physician, got another ambulance to come with EMT (Emergency Medical Technician) to assist with CPR. We transported the patient to Hospital # 2. He stated that hospital staff worked the code for about 5 minutes and pronounced the patient dead