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The Condition of Participation: Governing Body was out of compliance.

Based on records reviewed and interviews, the Hospital failed to ensure an effective Governing Body was responsible for the conduct of the Hospital, when the Hospital failed to have an adequate institutional budget for supplies and equipment, failed to maintain an adequate stock of supplies and equipment, resulting in supply issues related to vendor holds due to non-payment and failed to implement actions to address these non-payment issues to vendors.

Cross Reference:
482.12(d)(7): Governing Body: Institutional Plan and Budget (0077)
482.21(a), (c)(2), (e)(3): Quality Assessment and Performance Improvement: Patient Safety (0286)

Based on documents reviewed and interviews, the Hospital failed to have an adequate institutional budget for supplies and equipment, failed to maintain an adequate stock of supplies and equipment, resulting in supply issues related to vendor holds due to non-payment and failed to implement actions to address these non-payment issues to vendors.

The Hospital's Quality and Safety Plan, dated December 2022, indicated the Hospital Board of Directors holds overall responsibility and accountability for the quality of patient care, including the safety of patients, staff and visitors and the appropriate utilization of resources. The Hospital Board holds the Hospital Medical Staff accountable for the quality of patient care. Medical staff leadership together with hospital administrative leadership oversees hospital provision of care, treatment, and services, as well as day to day operations of the hospital.

Review of Board of Directors meeting minutes and notes indicated the following:
-March 30, 2023: System update- Utah hospitals divesture expected to go through around May 1st bringing more financial stability.
-December 20, 2023-Challenges: equipment and supplies. Fairly constant issues (due to credit holds) with Respiratory and Anesthesia supplies; Interventional supplies for Interventional Radiology (IR) and some surgical areas; medications; broken beds with no backups so several rooms down.

During an interview on 12/20/23 at 11:21 A.M., the Senior Director of Supply Chain said she oversees the central storeroom which supplies items for the floors and that units that perform specialty procedures order the specialty items themselves. She said items on consignment are brought in by the vendor and paid for after the case and as products are used the department will reorder the items using a bill and replace system. The Senior Director of Supply Chain said there have been a variety of items that had vendor holds placed due to payment issues or not receiving payment. The Senior Director of Supply Chain said staff will make her aware if they haven't received an ordered item and she will investigate to see if there is a hold due to payment issue. She said if there are vendor holds in place, she will ask questions about the item to see how critical it is and try to find a work round to get the item. The Senior Director of Supply Chain said her understanding is that all payments are sent via the Hospital's corporate headquarters and said she tries to manage past due invoices by notifying the senior leadership team at the Hospital of payment issues.
During an interview on 12/21/23 at 10:55 A.M., the Hospital President said that vendor payments are centralized by the corporate office and the Hospital does not issue payments directly. The Hospital President said there are different ways of learning about issues with vendors and payments and he said once he is notified about a vendor hold, he will try to get a similar item from a different vendor. The Hospital President said bills aren't paid due to a liquidity problem and said the Hospital Board of Directors is aware of the financial difficulties of the Hospital but was unable to say any actions implemented to maintain adequate supplies and equipment and to address non-payment to vendors.

During an interview on 1/29/24 at 3:54 P.M., the Hospital President said the corporate office approves each year's budget and said the Hospital's Board of Directors helps hospital leadership come up with goals of the organization. The Hospital President said financial stability is part of the Hospital's quality program and Board meeting high level planning is communicated to the regional team.

During an interview on 1/29/24 at 4:08 P.M., the Hospital President said that 12 of 22 consignment vendors (vendors that provide products that are paid for after being used) for the Hospital were on credit hold due to payment issues.

During a follow up interview on 1/30/24 at 2:27 P.M., the Hospital President said company product and vendor challenges are mainly due to credit hold issues. The Hospital President said he has kept the regional team aware of concerns of the Hospital's Board of Directors but was unable to provide evidence that the Governing Body implemented actions to address non-payments to vendors.

During an interview on 2/6/24 at 9:27 A.M., the Hospital President said there were multiple elevators out of service in the Hospital and that the previous elevator vendor stopped working with the Hospital due to not being paid.

The Hospital failed to implement actions to address non-payment issues to vendors, resulting in supply and equipment issues due to vendor holds for non-payment.

The Condition of Participation: Quality Assessment and Performance Improvement Program (QAPI) was out of compliance.

Based on records reviewed and interviews, for one of 10 sampled patients (Patient #1), the Hospital failed to ensure the Quality Assessment and Improvement Program (QAPI) implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment, and performance improvement program to implement preventative actions in response to preventable adverse patient events.

Cross Reference:
482.21(a), (c)(2), (e)(3): Quality Assessment and Performance Improvement: Patient Safety (0286)

Based on records and documents reviewed, and interviews, for one of 10 sampled patients (Patient #1), the Hospital failed to ensure the Quality Assessment and Improvement Program (QAPI) implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment, and performance improvement program to implement preventative actions in response to preventable adverse patient events.

The Hospital's Policy titled, Incident Reports: General Overview, revised 7/11/23, indicated that the Hospital responds to all incidents in a timely, consistent, and effective manner and that every incident will activate an appropriate investigation and response.

The Hospital's Quality and Patient Safety Plan, dated December 2022, indicated that review of adverse events and systems and process failures that meet certain criteria will be accomplished in part through the mechanism of Root Cause Analysis, a systematic approach of individual or pattern problem identification, followed by the institution of appropriate measures to improve patient care, safety, and patient satisfaction and reduce the likelihood of recurrence.

Review of Patient #1's General Surgery Operative Note, dated 10/17/23, indicated Patient #1 had a vaginal birth earlier in the day, experienced vaginal bleeding post-delivery and later required Dilation and Curettage (D & C) (a surgical procedure in which the cervix is dilated and examined in order to view and remove abnormal tissues) for the vaginal bleeding. The Note further indicated Patient #1's bleeding was well controlled for many hours before Patient #1 ultimately had a change in mental status and had hemoperitoneum (blood in the peritoneal cavity). Patient #1 was taken to the Operating Room (OR) for exploratory laparotomy (a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury) by the Obstetrics and Gynecology team (GYN), and went into Pulseless Electrical Activity arrest (PEA) (when the heart stops beating because the electrical activity is too weak to make the heart beat) shortly after arrival. Patient #1 received Cardiopulmonary Resuscitation (CPR) and return of spontaneous circulation was achieved. Intraoperatively, Patient #1 was found to have hemoperitoneum from an unidentified source, requiring packing above and around the liver, which somewhat controlled the bleeding and multiple liver hematomas and lacerations were observed. Patient #1 was ultimately accepted for transfer to an outside hospital by the Interventional Radiology (IR) service for coil embolization (a procedure in which metallic occluding coils are used to stop bleeding) of the dominant bleeding. Patient #1's estimated blood loss was 6 liters.

Review of Patient #1's GYN Operative Note, dated 10/17/23, indicated Patient #1 went into cardiac arrest after arrival to the operative room, advanced cardiovascular life support (ACLS) was started and after cardiac activity was resumed, Patient #1 was prepped for an exploratory laparotomy. The Note further indicated a large hemoperitoneum was noted and over 2 liters of blood was evacuated from the abdomen, the uterus appeared normal with no evidence of perforation, additionally, a large clot was removed from Patient #1's right upper quadrant and heavy bleeding was noted from the liver and the trauma surgical team was called. The Note further indicated Patient #1 received packing to the right upper quadrant and abdomen and Patient # 1 was sent out for an interventional radiology procedure at an outside tertiary hospital.

Review of the Tertiary Hospital's (the hospital that Patient #1 was transferred to) Interventional Radiology Consult note dated 10/18/23 indicated that Patient #1 had experienced postpartum bleeding and hemoperitoneum (blood in the peritoneum) and had been transferred from the Hospital via MediFlight due to insufficient materials at the Hospital for embolization.

During an interview on 12/19/23 at 1:00 P.M., the Chief Medical Officer said she was aware of Patient #1's case and had been present the night of the event. The Chief Medical Officer said Patient #1 was bleeding from the right upper quadrant and there were multiple liver lacerations. The Chief Medical Officer said that the bleeding had been controlled using a Pringle maneuver (a procedure to stop the flow of blood through the hepatic artery and controls bleeding from the liver) but this is not a permanent solution. The Chief Medical Officer said a call was made to Interventional Radiology (IR) to notify them that Patient #1 needed embolization, but she was told the IR didn't have the needed embolization coils. The Chief Medical Officer said the Hospital had the technical skills but not the coils, due to no one monitoring par levels.

During a follow up interview on 12/21/23 at 9:18 A.M., the Chief Medical Officer said she had been notified by the Chair of Radiology prior to Patient #1's event that a vendor had taken the embolization coils, conflicting with a previous interview which indicated the coils were unavailable due to Hospital staff failing to maintain par levels, and said the Hospital was considering not taking GI bleed patients due to not having the coils. The Chief Medical Officer said a vendor rep came and took the coils and that she was unsure who released the payment to vendors, as they all come through the corporate office.

During an interview on 12/20/23 at 8:12 A.M., IR Technician (Tech) #1 said the Hospital has a specific IR suite and supply room, which was stocked with equipment and supplies, which typically included embolization coils. IR Tech #1 said he maintains IR supplies and stock (PAR levels) and his system was to take the sticker from each procedure after it was completed, and immediately scan it to re-order and replace the used item. He said this PAR level maintenance system had been in place for a few years and there were never issues with IR items not being available. IR Tech #1 said that at the time of Patient #1's event, the embolization coils were on consignment from the Vendor. IR Tech #1 said sometime in early October 2023, he received an email from the Vendor's representative notifying the Hospital that the Vendor planned to take the coils back due to not receiving payment and the coils were removed sometime around 10/12/23. IR Tech #1 said he notified his manager of the Vendor's email and also notified his manager when the coils were taken by the Vendor representative prior to Patient #1's event on 10/17/23. IR Tech #1 said his understanding was there were no coils available in the hospital at the time of the event, as they were all on consignment and had been taken by the vendor.

Review of vendor email to the Hospital dated 10/3/23 indicated that the vendor had been waiting for payment from the Hospital that had not been received and the vendor was planning to pick up the coils that were in the Hospital.

During an interview on 12/20/23 at 11:21 A.M., the Senior Director of Supply Chain said items on consignment are brought in by the vendor and paid for after the case and as products are used the department will reorder the items using a bill and replace system. The Senior Director of Supply Chain said there have been a variety of items that had vendor holds placed due to payment issues or not receiving payment. The Senior Director of Supply Chain said staff will make her aware if they haven't received an ordered item and she will investigate to see if there is a hold due to a payment issue. She said if there are vendor holds in place, she will ask questions about the item to see how critical it is and try to find a work round to get the item. The Senior Director of Supply Chain said her understanding is that all payments are sent via the Hospital's corporate headquarters and said she tries to manage past due invoices by notifying the senior leadership team at the Hospital of payment issues.

During an interview on 12/20/23 at 2:16 P.M., the Director of Radiology and Radiation Oncology said he notified upper levels of management that the coils had been taken but was unable to say how many days the Hospital did not have the coils.

During an interview on 12/21/23 at 10:55 A.M., the Hospital President said Patient #1's case was an extremely difficult case. The President said his understanding of the coils being unavailable on 10/17/23 was due to the vendor pulling the coil supply due to non-payment. The President said he was aware of the coils being pulled prior to Patient #1's event and said all bill payments are paid by the Hospital corporate offices and that some bills aren't being paid due to a liquidity problem. The Hospital President said that after this event he sent an email to department leaders after the event to notify them that if a vendor tries to take consigned items back due to payment issues to not let that happen but was unable to provide evidence of any additional corrective actions implemented to address vendor non-payments.

During a follow up interview on 1/30/24 at 2:27 P.M., the Hospital President said company product and vendor challenges are mainly due to credit hold issues. The President said the Quality Assurance and Performance Improvement (QAPI) team does not discuss financial issues because there are senior level managers that are already aware of payment issues and challenges with staffing and further said that access to supplies and equipment can impact quality and safety.

The Hospital failed to implement any corrective actions towards managing vender accounts to ensure any necessary medical equipment is not repossessed due to non-payment, failed to provide any evidence of tracking and trending payment issues impacting supplies and services. The Hospital also failed to provide any evidence of corrective actions related to the Hospital maintaining par levels of necessary medical equipment or interventions in the event necessary medical equipment is not available during an emergency.

The Hospital was out of compliance with the Condition of Participation for Surgical Services.

Based on records and documents reviewed, and interviews: 1) The Hospital failed to provide the appropriate equipment necessary to furnish the surgical services offered by the Hospital in accordance with the acceptable standards of practice which resulted in one of 10 sampled patients (Patient #1) not receiving emergency treatment with an embolization coil, which was unavailable due to repossession by the coil vendor for Hospital non-payment. 2) The Hospital failed to ensure payments were made to vendors and suppliers as evidenced by failing to maintain an inventory of mechanical heart valves used for Type A Aortic Dissections (a medical emergency that occurs when a tear develops in the ascending part of the aorta as it branches off from the heart) due to failure to pay the vendor and the Hospital was on diversion for Aortic Dissections due to the missing mechanical heart valves.

Immediate Jeopardy (IJ) was identified on 2/2/24 under 482.51 Surgical Services due to failure of the Hospital to ensure appropriate medical equipment necessary for furnishing surgical services was available. Patient #1 was transferred to an outside tertiary hospital for an emergency embolization procedure secondary to the Hospital not having the necessary coils for the procedure due to failure to pay the vendor. The Hospital replaced the inventory by changing vendors but continued to have supply issues due to nonpayment of vendors as evidenced by not having inventory of mechanical heart valves used for emergent Type A Aortic Dissections due to nonpayment and being on diversion for Aortic Dissections.

The Hospital was notified of the IJ on 2/2/24. The Hospital provided an immediate corrective action plan on 2/8/24. In summary, the IJ event Removal Plan was implemented on 2/8/24.

The IJ event regarding the CoP of Surgical Services was removed on 2/8/24, when the State Agency/CMS verified by interview with staff, review of all documentation, education attestations, and Patient records that the Removal Plan was fully implemented.

Condition of Participation non-compliance for Surgical Services remain.

Cross Reference:
482.51(a): Organization and Staffing (941)

Based on records and documents reviewed, and interviews: 1) The Hospital failed to provide the appropriate equipment necessary to furnish the surgical services offered by the Hospital in accordance with the acceptable standards of practice which resulted in one of 10 sampled patients (Patient #1) not receiving emergency treatment with an embolization coil, which was unavailable due to repossession by the coil vendor for Hospital non-payment. 2) The Hospital failed to ensure payments were made to vendors and suppliers as evidenced by failing to maintain an inventory of mechanical heart valves used for Type A Aortic Dissections (a medical emergency that occurs when a tear develops in the ascending part of the aorta as it branches off from the heart) due to failure to pay the vendor and the Hospital was on diversion for Aortic Dissections.

1) Patient #1 presented to the Hospital on 10/15/23 for induction of labor and had a vaginal delivery on 10/17/23. Review of Patient #1's medical record indicated Patient #1 had received a prolonged high dose of intravenous (IV) Pitocin (a hormone used to help the uterus contract) during the labor process and subsequently received prophylactic Methergine (a medication to prevent and control bleeding from the uterus after childbirth) and Cytotec (a medication used to prevent postpartum hemorrhage) after delivery.

Review of Patient #1's General Surgery Operative Note, dated 10/17/23, indicated Patient #1 had a vaginal birth earlier in the day, experienced vaginal bleeding post-delivery and later required Dilation and Curettage (D & C) (a surgical procedure in which the cervix is dilated and examined to view and remove abnormal tissues) for the vaginal bleeding. The Note further indicated Patient #1's bleeding was well controlled for many hours before Patient #1 ultimately had a change in mental status and had hemoperitoneum (blood in the peritoneal cavity). Patient #1 was taken to the Operating Room (OR) for exploratory laparotomy (a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury) by the Obstetrics and Gynecology team (GYN), and went into Pulseless Electrical Activity arrest (PEA) (when the heart stops beating because the electrical activity is too weak to make the heart beat) shortly after arrival. Patient #1 received Cardiopulmonary Resuscitation (CPR) and return of spontaneous circulation was achieved. Intraoperatively, Patient #1 was found to have hemoperitoneum from an unidentified source, requiring packing above and around the liver, which somewhat controlled the bleeding and multiple liver hematomas and lacerations were observed. Patient #1 was ultimately accepted for transfer to an outside hospital by the Interventional Radiology (IR) service for coil embolization (a procedure in which metallic occluding coils are used to stop bleeding) of the dominant bleeding. Patient #1's estimated blood loss was 6 liters.

Review of Patient #1's GYN Operative Note, dated 10/17/23, indicated Patient #1 went into cardiac arrest after arrival to the operative room, advanced cardiovascular life support (ACLS) was started and after cardiac activity was resumed, Patient #1 was prepped for an exploratory laparotomy. The Note further indicated a large hemoperitoneum was noted and over 2 liters of blood was evacuated from the abdomen, the uterus appeared normal with no evidence of perforation, additionally, a large clot was removed from Patient #1's right upper quadrant and heavy bleeding was noted from the liver and the trauma surgical team was called. The Note further indicated Patient #1 received packing to the right upper quadrant and abdomen and Patient # 1 was sent out for an interventional radiology procedure at an outside hospital.

Review of the Tertiary Hospital's (the Hospital where Patient #1 was emergently transferred to) Interventional Radiology Consult Note, dated 10/18/23, indicated that Patient #1 had experienced postpartum bleeding and hemoperitoneum and had been transferred from the Hospital via MedFlight due to insufficient materials at the Hospital for embolization.

During an interview on 12/20/23 at 11:51 A.M., the Interventional Radiologist said he was on call the night of Patient #1's event. He said he was notified of a postpartum patient with intra-abdominal bleeding that appeared to be from Patient #1's liver. The Interventional Radiologist said that at the time of the event, the Hospital did not have embolization coils and the IR tech confirmed there were no coils, and he notified the team in the OR that the embolization coils were not available.

During an interview on 12/19/23 at 10:07 A.M., the Chief Medical Officer said the hospital is equipped for trauma cases, that the Hospital is a tertiary center and receives patients that require trauma services.

During an interview on 12/19/23 at 1:00 P.M., the Chief Medical Officer said she was aware of Patient #1's case and had been present the night of the event. The Chief Medical Officer said she arrived at the OR and Patient #1 was being worked on by Attending OB #1 and General Surgeon #1. The Chief Medical Officer said Patient #1 was bleeding from the right upper quadrant and there were multiple liver lacerations. The Chief Medical Officer said that the bleeding had been controlled using a Pringle maneuver (a procedure to stop the flow of blood through the hepatic artery and controls bleeding from the liver) but this is not a permanent solution. The Chief Medical Officer said a call was made to Interventional Radiology (IR) to notify them that Patient #1 needed embolization, but she was told the IR didn't have the needed embolization coils. The Chief Medical Officer said the Hospital had the technical skills but not the coils, due to no one monitoring par levels and the decision was made to send Patient #1 to an outside hospital for the embolization.

During a follow up interview on 12/21/23 at 9:18 A.M., the Chief Medical Officer said she had been notified by the Chair of Radiology prior to Patient #1's event that a vendor had taken the embolization coils, conflicting with a previous interview which indicated the coils were unavailable due to Hospital staff failing to maintain par levels, and said the Hospital was considering not taking GI bleed patients due to not having the coils. The Chief Medical Officer said a vendor rep came and took the coils and that she was unsure who released the payment to vendors, as they all come through the corporate office.

During interviews on 12/19/23 at 1:23 P.M. and throughout the survey, General Surgeon #1 said he received an urgent request at approximately 8:50 P.M. on 10/17/23 to assist in surgery for Patient #1. General Surgeon #1 said he arrived a little after 9:00 P.M. and identified Patient #1's liver as the presumed bleeding source. General Surgeon #1 said Patient #1 had a midline incision and most of Patient #1's abdomen was packed, and Patient #1 had already received 3 units of blood and other products. General Surgeon #1 said he decided to implement a Pringle maneuver. General Surgeon #1 said he counted several liver lesions and lacerations but was unable to determine which was the main bleed. General Surgeon #1 said every time the Pringle was released, the lacerations would bleed profusely with torrential blood coming out. General Surgeon #1 said IR coil embolization of the liver could typically be done at the Hospital and said that the Hospital had the expertise, but they didn't have the coils to use on Patient #1 in attempts to stop the excessive bleeding. General Surgeon #1 said Patient #1 was transferred to a Tertiary Hospital for the embolization procedure.

During an interview on 12/20/23 at 8:12 A.M., IR Technician (Tech) #1 said the Hospital has a specific IR suite and supply room, which was stocked with equipment and supplies, which typically included embolization coils. IR Tech #1 said he maintains IR supplies and stock (PAR levels) and his system was to take the sticker from each procedure after it was completed, and immediately scan it to re-order and replace the used item. He said this PAR level maintenance system had been in place for a few years and there were never issues with IR items not being available. IR Tech #1 said that at the time of Patient #1's event, the embolization coils were on consignment from the Vendor. IR Tech #1 said sometime in early October 2023, he received an email from the Vendor's representative notifying the Hospital that the Vendor planned to take the coils back due to not receiving payment and the coils were removed sometime around 10/12/23. IR Tech #1 said he notified his manager of the communication that the Vendor was planning on taking the coils back due to non-payment and again when the coils were taken. IR Tech #1 said his understanding was there were no coils available in the hospital at the time of the event, as they were all on consignment and had been taken by the vendor.

Review of vendor email to the Hospital dated 10/3/23 indicated that the vendor had been waiting for payment from the Hospital that had not been received and the vendor was planning to pick up the coils that were in the Hospital.

During an interview on 12/20/23 at 2:16 P.M., the Director of Radiology and Radiation Oncology said that IR Tech #1 notified him that the Vendor provided notification that the Vendor representative planned to remove the coils from the Hospital. The Director said he told IR Tech #1 not to release the coils back to the Vendor but to request the Vendor representative contact the Director and administration. The Director said he was notified when the coils were removed from the Hospital and said he then notified the Corporate Director of Radiology and upper levels of management. The Director was unable to say when the coils were taken, or any actions taken to address possible safety issues related to the coils being taken.

During an interview on 12/20/23 at 11:21 A.M., the Senior Director of Supply Chain said there have been a variety of items that had vendor holds placed due to payment issues or not receiving payment. The Senior Director of Supply Chain said staff will make her aware if they haven't received an ordered item and she will investigate to see if there was a hold due to a payment issue. She said if there are vendor holds in place, she will ask questions about the item to see how critical it was and try to find a work round to get the item. The Senior Director of Supply Chain said her understanding is that all payments are sent via the Hospital's corporate headquarters and said she tries to manage past due invoices and notify the senior leadership team at the Hospital of payment issues.

During an interview on 12/21/23 at 10:55 A.M., the Hospital President said Patient #1's case was an extremely difficult case. The President said his understanding of the coils being unavailable on 10/17/23 was due to the vendor pulling the coil supply due to non-payment. The President said he was aware of the coils being pulled on 10/17/23, prior to Patient #1's event, and said all bill payments are paid by the Hospital corporate offices and that some bills aren't being paid due to a liquidity problem. The Hospital President said that after this event he sent an email to department leaders after the event to notify them that if a vendor tries to take consigned items back due to payment issues to not let that happen but was unable to provide evidence of any corrective actions implemented to address vendor non-payments or potential safety issues related to vendor non-payment.

2) The Hospital failed to ensure payments were made to vendors and suppliers as evidenced by the Hospital failing to maintain an inventory of mechanical heart valves used for Type A Aortic Dissections (a medical emergency that occurs when a tear develops in the ascending part of the aorta as it branches off from the heart) due to failure to pay the vendor. The Hospital was subsequently on diversion for Aortic Dissections.

During an interview on 1/31/24 at 7:20 A.M., the Chief Medical Officer provided the surveyor with a list of procedures that the Hospital was unable to perform due to supply issues and said the Hospital was on diversion for Aortic Dissections (a medical emergency that occurs when a tear develops in the ascending part of the aorta as it branches off from the heart) due to lack of a specific mechanical valve (valved aortic graft).

During an interview on 12/21/23 at 10:55 A.M., the Hospital President said all bill payments are paid by the Hospital corporate offices and that some bills aren't being paid due to a liquidity problem and the Hospital has had issues with vendors putting accounts on hold or not delivering products due to non-payment.

During a follow up interview on 1/29/24 at 11:13 A.M., the Senior Director of Supply Chain said she has lots of concerns with supplies and vendors due to non-payment. She said the Hospital was not taking patients that need certain types of procedures and that she and her staff try to find and source alternate supplies to replace supplies that are on vendor payment hold.

During an interview on 1/31/24 at 8:47 A.M., the Hospital President said the item needed to treat an Aortic Dissection was unavailable due to payment issues and the vast majority of supply issues were due to credit holds.

During an interview on 2/1/24 at 10:36 A.M., the Chief of Cardiac Surgery said most aortic dissections are acute and that the Hospital did not have a specific size mechanical valve that can be used to treat a Type A Aortic Dissection.

Review of Hospital email communication with the mechanical valve vendor indicated a request was made for a valved graft 11/7/23 and due to credit review, the vendor would not fulfill the order.

The Hospital failed to ensure payments were made to vendors and suppliers in order to maintain necessary emergency supplies and equipment, in accordance with acceptable standards of practice.