HospitalInspections.org

Based on review of facility documentation, observations, and employee interviews (EMP), it was determined the facility failed to function as a hospital as defined by the Social Security Act, in that they were not primarily engaged in providing services to inpatients. The facility inpatient census was zero during two onsite visits on August 20, 2019, and September 20, 2019.

Findings include:

Review of the "Social Security Act," section 1861(e)(1), revealed, "(e) The term "hospital" means an institution which-(1) is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (b) rehabilitation services for the rehabilitation of injured, disabled, or sick persons."

At the time of entrance on August 20, 2019, both EMP1 and EMP2 confirmed that the facility is only open Monday through Friday.

Signage on the hospital main entrance stated that the doors are locked from 6:00 PM to 6:00 AM, Monday through Friday.

Review, between 10:45 AM and 12:00 PM on August 20, 2019, of untitled reports provided by EMP2 revealed that for the month of August 2018, the facility had five inpatients that stayed for a combined total of 339 hours and 23 minutes; in September 2018, the facility had three inpatients that stayed for a combined total of 183 hours and 53 minutes; in October 2018, the facility had three inpatients that stayed for a combined total of 229 hours and 34 minutes; in November 2018, the facility had four inpatients that stayed for a combined total of 304 hours and 40 minutes; in December 2018, the facility had one inpatient that stayed for a total of 76 hours and 37 minutes; in January 2019, the facility had six inpatients that stayed for a combined total of 401 hours and 39 minutes; in February 2019, the facility had three inpatients that stayed for a combined total of 232 hours and 15 minutes; in March 2019, the facility had three inpatients that stayed for a combined total of 230 hours and 17 minutes; in April 2019, the facility had three inpatients that stayed for a combined total of 229 hours and 13 minutes; in May 2019, the facility had three inpatients that stayed for a combined total of 179 hours and two minutes; in June 2019, the facility had seven inpatients that stayed for a combined total of 538 hours and 35 minutes; and in July 2019, the facility had two inpatients that stayed for a combined total of 155 hours and four minutes.

Utilizing the above information, it was determined that the facility's average length of stay was 3.02 days; with an average of four inpatients per month; and an average daily census of 0.01. This is due to the facility not operating on Saturday or Sunday.

A review of weekly staffing schedules beginning June 25, 2018, to July 29, 2019, was conducted on August 20, 2019, at approximately 1:25 PM. The review revealed each weekly schedule (Monday through Sunday) was marked "Closed," "Open" or "Inpatient."

On August 20, 2019, at approximately 1:28 PM, when asked to clarify the weeks marked "Closed," EMP2 stated, "The closed weeks we don't do inpatients. The open weeks we have more staff." When asked to confirm that inpatient (procedures) are only done during weeks marked open (or inpatient), EMP2 stated, "Yes."

For the 52 weekly staffing schedules reviewed, nine weeks were marked as "Open" or "Inpatient." The remaining 43 weeks were marked as "Closed."

The review of weekly staffing schedules beginning June 25, 2018, to July 29, 2019, revealed 24/7 staffing by nursing.

On August 20, 2019, at approximately 1:50 PM, EMP2 confirmed that 43 of the 52 weeks of schedules were closed weeks for inpatients.



A second survey attempt was conducted on September 20, 2019.

On September 20, 2019, an unannounced on-site recertification was attempted. At the time of entrance, there were no inpatients at the facility.

On September 20, 2019, at approximately 10:00 AM, observation of a sign posted at the main entrance revealed, "Outpatient Walk-in Laboratory Services New Days & Times Starting 8/3/19 Monday 9a-1pm Tuesday 9a-1pm Wednesday-Closed Thursday 9a-1pm Friday-Closed Also-All X-Rays will need to be pre-scheduled. No walk-in x-rays. If you arrive for lab work [sic.] BEFORE 9am on these days, please note you may have a wait time. Must have physician order for lab work. Edgewood Surgical Hospital."

On September 20, 2019, at approximately 10:15 AM, observation of signage in Patient Room #6 (empty) revealed, "Patient Safety Measures Dear Patient, A doctor of medicine or of osteopathy is not present in the hospital twenty-four (24) hours a day, 7 days a week. In the event a patient develops an emergency medical condition at a time when no physician is present at the Hospital, the Hospital's qualified medical personnel will provide stabilizing treatment to the patient within its capabilities and in accordance with the Hospital's emergency condition policies and procedures until the patient is either stabilized or, if the emergency is outside the scope of the Hospital's capabilities, until the patient is transported to another hospital. ... Thank you Administration Edgewood Surgical Hospital."

On September 20, 2019, at approximately 11:00 AM, review of Policy # IP PC 30.0, "Providing Emergency Services," Original Date March 2004, revealed, "PURPOSE: In the event a person presents themselves at the hospital with an emergency medical condition. POLICY: The hospital does not provide emergency services or an emergency room, but the potential exists that a person requiring emergency care may come to the Edgewood Surgical Hospital seeking medical care. ... 3. An initial assessment of the patient will be made ... If deemed necessary, CPR and first aid treatment will be implemented. 4. The Anesthesiologist or Physician (if in the building) or on call will be promptly be notified, orders will be obtained and initial treatment will be started while the physician is in route to the hospital."

A review, beginning September 20, 2019, and concluding on October 2, 2019, of inpatient census and length of stay reports for Edgewood Surgical Hospital, for September 20, 2018, through September 20, 2019, revealed zero inpatient days for September 20-30, 2018; nine inpatient days for three inpatients in October 2018; twelve inpatient days for four inpatients in November 2018; three inpatient days for one inpatient in December 2018; fifteen inpatient days for six inpatients in January 2019; nine inpatient days for three inpatients in February 2019; nine inpatient days for three inpatients in March 2019; nine inpatient days for three inpatients in April 2019; seven inpatient days for three inpatients in May 2019; 21 inpatient days for seven inpatients in June 2019; six inpatient days for two inpatients in July 2019; twelve inpatient days for four inpatients in August 2019; and three inpatient days for one inpatient from September 1-20, 2019. This equated to an Average Length of Stay (ALOS) of approximately 2.88 days. Additionally, utilizing the above information, the Average Daily Census (ADC) equates to approximately 0.31.

A review, beginning September 20, 2019, and concluding October 2, 2019, of inpatient procedures and outpatient procedures for both Edgewood Surgical Hospital and Lawrence County Surgery Center of Edgewood Surgical Hospital [hospital-based], for September 20, 2018, through September 20, 2019, revealed the following: Zero inpatient procedures and 95 outpatient procedures from September 20-30, 2018. Three inpatient procedures and 400 outpatient procedures in October 2018. Four inpatient procedures and 327 outpatient procedures in November 2018. One inpatient procedure and 228 outpatient procedures in December 2018. Six inpatient procedures and 250 outpatient procedures in January 2019. Three inpatient procedures and 203 outpatient procedures in February 2019. Three inpatient procedures and 244 outpatient procedures in March 2019. Three inpatient procedures and 259 outpatient procedures in April 2019. Three inpatient procedures and 293 outpatient procedures in May 2019. Seven inpatient procedures and 263 outpatient procedures in June 2019. Two inpatient procedures and 279 outpatient procedures in July 2019. Four inpatient procedures and 300 outpatient procedures in August 2019. One inpatient procedure and 176 outpatient procedures from September 1-20, 2019.

Review of the nursing schedules for September 20, 2018, through September 20, 2019, revealed, consistently, that nursing staff included in the categories of "Day Shift," "Pre-op/PACU," and "Operating Room," are not scheduled on weekends or holidays. Review of the weekend staffing revealed that on all dates except otherwise noted, there was one RN scheduled for the 24 hour periods over the weekend and holidays. Below are the exceptions:

October 28, 2018: No identified coverage from 5:00 PM-5:30 AM on October 29, 2018.
November 4, 2018: No identified coverage from 5:00 PM-10:00 PM.
November 18, 2018: No identified coverage from 5:00 PM to 5:30 AM on November 19, 2018.
November 25, 2018: No identified coverage from 5:00 PM to 10:00 PM.
December 9, 2018: No identified coverage from 7:00 PM to 5:30 AM on December 10, 2018.
December 16, 2018: No identified coverage from 7:00 PM to 10:00 PM.
December 24, 2018: No identified coverage from 7:00 AM to 4:00 PM.
December 30, 2018: No identified coverage from 5:00 PM to 4:00 PM on December 31, 2018.
January 6, 2019: No identified coverage from 7:00 PM to 10:00 PM.
March 24, 2019: No identified coverage from 5:00 PM to 7:00 PM.
May 19, 2019: No identified coverage from 3:00 PM to 5:00 PM.
July 7, 2019: No identified coverage from 3:00 PM to 5:00 PM.

Review of CRNA schedules for the period September 20, 2018, through September 20, 2019, was conducted. Review of the schedule revealed no Sunday coverage and no Saturday coverage with the exception of eight days (10/13/18, 11/17/18, 01/19/19, 03/23/19, 04/13/19, 06/29/19, 07/20/19 and 08/17/19). The review further revealed no holiday coverage for (2018) New Year's Eve, (2019) Memorial Day, July 4 and Labor Day. Holiday coverage for the Lawrence County Surgery Center of Edgewood Surgical Hospital (Satellite Outpatient Surgery Center) had no holiday coverage with the exception of (2018) Christmas Day and (2019) New Year's Day.

On September 20, 2019, when asked about the weekend activity for CRNA coverage related to schedules provided for September 2018 to September 2018, EMP2 stated, "We haven't had any of them come in over the weekend in the past year."

Review of Radiology/Rad Tech schedules for the period September 20, 2018, through September 20, 2019, revealed no Saturday or Sunday radiology coverage with MRI marked closed on Sundays. Review of weekday coverage revealed multiple weekdays per month with limited or no coverage.

Review of Lab for the period September 20, 2018, through September 20, 2019, revealed no Sunday coverage. Review of Saturday coverage revealed AM PRN (as needed) coverage AM only for Inpatient Weeks. Review of weekday coverage revealed multiple weekdays per month with limited or no coverage.

Review of Holiday Coverage for Radiology and Lab revealed the services were closed (2018) Christmas Eve, Christmas Day, New Year's Eve, (2019) New Year's Day, Memorial Day, and Labor Day.

Review of time cards for the facility Pharmacist for the period September 20, 2018, through September 20, 2019, revealed no Saturday or Sunday coverage. The review further revealed multiple weekdays with no pharmacy coverage. Additional review revealed bi-weekly pharmacy hourly coverage totals of between 4.5 hours and 12.25 hours.

Review of time cards for the facility Dietary Staff for the period September 20, 2018, through September, 20 2019, (Timecard Gap between 06/29/19 & 08/11/19) revealed no Saturday or Sunday coverage. The review further revealed 11 weeks with no Dietary coverage. Days with coverage time from sign-in to sign-out (only one employee) ranged from 1-4 total Dietary coverage hours.

Review of the housekeeping schedule for September 20, 2018, through September 20, 2019, revealed that this individual is not scheduled on holidays or weekends; and when scheduled, is a consistent shift of 9:00 AM-5:30 PM.

Review of the Administrative/Office Staff schedule for September 20, 2018, through September 20, 2019, revealed documentation of weekday coverage only. No evenings, weekends, or holidays were noted to be covered by these individuals.