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Based on interview and record review the facility continued to fail to maintain any inpatient admissions and thereby failed to provide critically needed inpatient services for which it was designated as a Critical Access Hospital (refer to C 0211)

The cumulative effect of this ongoing systemic failure resulted in the facility's continued overall noncompliance with 42 CFR 485.620 Condition of Participation: Number of Beds and Length of Stay.

This standard remains uncorrected. For additional examples please refer to the 2567 dated 06/13/12.

Based on interview with hospital management and physicians (Staff #A, #G, #H, #L and #M), interview with transferred patients and/or their next of kin for two patients (Patients #10 and #14), and record review of five (Patients #6, #10, #14, #16, #22) of twenty five transferred patients, the facility continued to fail to admit patients to the facility when there was capacity and capability to admit patients and thereby failed to use certified Critical Access Hospital (CAH) inpatient beds for inpatient care. The CAH's census was 0 for all days of the survey.

Findings included:

1. During an interview on 08/07/12 at 1:15 PM Staff A, Administrator, stated the following:
-The CAH did not have any inpatients.
-The CAH had not admitted any inpatients since the last survey (06/11/12 through 06/13/12.)
-The CAH had no plans to admit any inpatients in the future;
-The Administrator felt the needs of the community were being met (even though the CAH did not admit inpatients).

2. Record review of the facility Emergency Department (ED) logs (a list of all patients treated in the ED) for the months of June, 2012, July, 2012 and the first five days of August, 2012 showed none of the patients were admitted to Parkland Health Center (they were treated and discharged or treated and transferred to other hospitals).

3. Review of the CAH's ED transfer list (a list of any patients who were on the ED logs, treated in the ED, then transferred to other hospitals) for the month of July, 2012 showed sixty two patients were evaluated by physicians, were transferred to other hospitals and none were admitted to Parkland Health Center for care.

Review of the CAH's ED transfer list for the first five days of August, 2012 showed six patients were evaluated, transferred to other hospitals, and none were admitted to Parkland Health Center for care.

4. During a telephone interview on 08/08/12 at 10:48 AM Staff G, Medical Director of the Emergency Department (ED) stated the following:
-ED physicians discuss admission with a Hospitalist physician at the nearby Hospital B.
-Hospitalists would have to "round" on the patients (go to the bedside of an admitted patient) by the next morning which means they'd have to come to this CAH.
-More motivation was required for physicians to agree to admit patients into this CAH.
-The diagnoses of patients who may possibly be admitted would include a patient who would need only intravenous fluids or a patient who may need intravenous antibiotics for a short stay as an inpatient.

5. Review of the medical record revealed Patient #10 came to the ED on 7/31/12 at 12:38 PM complaining of feeling dizzy, not thinking clear, and stated that her "blood sugar is always over 350". The ED physician examined Patient #10 and determined her diabetes was poorly controlled. At 6:40 PM Patient #10 received a dose of insulin through the intravenous (IV) catheter. At 7:37 PM the lab reported Patient #10's blood glucose level was critically elevated at 584 (normal is 70-100). At 7:46 PM Patient #10 received a second dose of insulin through the IV and the ED physician determined she required inpatient admission to stabilize her blood sugar. The ED physician documented on the transfer form the reason for transfer to Hospital B was "Higher level of Specialty Services Unavailable at this Facility", and specified the specialty service unavailable was "No admission". The ED physician documented on Hospital B's "Emergency Department Hospital Admission Orders" form that Patient #10 should be admitted as an inpatient (at Hospital B), that her condition was stable, that she could be up and about at will, that her vital signs should be checked every 4 hours, that her oral and IV intake and urine output should be measured every shift, that the IV fluids should continue, that she should eat an 1800 calorie diet, that nursing should check her blood sugars and administer insulin according to a sliding scale and that two blood tests should be obtained in the morning. All of these physician orders for inpatient care could have been provided at Parkland Health Center.

Review of Hospital B's medical record revealed Patient #10 was admitted as an inpatient sometime after 8:00 PM on 7/31/12 and was discharged at 1:25 PM on 8/3/12, for an inpatient stay of approximately 66 hours (within the 96 hour average length of stay limitation for CAHs).

During a telephone interview on 08/08/12 at 10:00 AM Patient #10 stated the following:
-The patient did not know the facility (Parkland Health Center) had inpatient beds.
-The ED physician did not say there were inpatient beds at the CAH.
-The ED physician called the patient's primary care physician and the physicians agreed to transfer the patient to the nearby Hospital B.

6. Review of the medical record revealed Patient # 14 presented to the ED on 7/31/12 at 12:01 AM complaining of left lower abdominal pain and a headache. The ED physician examined Patient # 14 and documented that her pain "feels like diverticulitis" (painful inflammation or infection in the digestive tract). At 1:14 AM the patient underwent a CT scan (series of x-rays taken from many different angels) of her abdomen and pelvis which confirmed the presence of diverticulitis without evidence of an abscess. At 3:15 AM the ED physician arranged to transfer Patient # 14 to Hospital B and diagnosed her with abdominal pain and diverticulitis. The ED physician documented on the transfer form the reason for transfer to Hospital B was " Higher level of Specialty Services Unavailable at this Facility " , and specified the specialty service unavailable was " Inpatient Services " . At 3:00 AM the ED physician documented on Hospital B ' s " Emergency Department Hospital Admission Orders " form that patient # 14 should be admitted as an inpatient (at Hospital B), that her condition was stable, that she could be up to the bathroom without assistance, that the nursing staff should check her vital signs (blood pressure, heart rate, respiratory rate, and temperature) every 4 hours for 24 hours, then per policy, that her oral intake and urine output should be monitored and recorded every shift, that she should eat a 2000 calorie diabetic diet, that her blood sugars should be checked before each meal and at bedtime, and ordered various intravenous and oral medications. All of these physician orders for inpatient care could have been provided at Parkland Health Center. Review of Hospital B ' s medical record revealed Patient # 14 was admitted as an inpatient at approximately 4:00 AM on 7/31/12 and was discharged at 8:30 AM on 8/1/12, for a stay of approximately 17 hours (within the 96 hour average length of stay limitation for CAHs).

During a telephone interview on 08/09/12 at 10:20 AM Patient #14 stated the following:
-No staff ever told the patient there were inpatient beds (at Parkland Health Center).
-No choice of inpatient treatment facilities was offered to the patient.
-The patient stayed overnight at the nearby Hospital B.
-The patient would have liked to stay at the CAH instead of being transferred.
-The CAH was closer to home (than Hospital B).

7. Review of the medical record revealed Patient # 6 came to the ED on 7/7/12 at 7:10 PM complaining of a migraine headache for 3 days, constipation, vomiting, fever and mid-abdominal pain. The ED physician examined the patient and ordered blood testing and a CT scan of her abdomen and pelvis. At 12:05 AM on 7/8/12 Patient # 6 received an intravenous (IV) dose of Flagyl (antibiotic frequently prescribed as treatment for inflammatory bowel disease) and a 2nd antibiotic (Levaquin) at 1:15 AM. At 12:15 AM the ED physician arranged to transfer the patient to Hospital B and diagnosed her with colitis, abdominal pain, and migraine headache. At 12:20 AM the ED physician documented on the transfer form the reason for transfer to Hospital B was " Higher level of Specialty Services Unavailable at this Facility: " and specified the specialty service unavailable was "Inpatient Services". The ED physician documented on Hospital B's "Emergency Department Hospital Admission Orders" form that patient # 6 was stable, that she could go to the bathroom with assistance, that her vital signs should be checked every 4 hours, then per policy, that her oral and intravenous intake and urine output should be measured every shift, that the IV fluids should continue, that two blood tests should be obtained in the morning and that she should receive additional doses of Flagyl and Levaquin through her IV along with a pain medication and a medication to prevent nausea. All of these physician orders for inpatient care could have been provided at Parkland Health Center. Review of Hospital B's medical record revealed Patient # 6 was admitted as an inpatient sometime after 3:00 AM on 7/8/12 and was discharged at 1:45 PM on 7/12/12 for an inpatient stay of approximately 83 hours (within the 96 hour average length of stay limitation for CAHs).

8. Review of the medical record revealed Patient # 16 came to the ED on 7/25/12 at 2:28 PM complaining of epigastric (above the stomach) pain. At 3:05 PM the ED physician examined the patient and documented she had right upper quadrant (of the abdomen) pain with nausea and that the nurse practitioner (the patient saw before coming to the ED) "suggested she might be having a heart attack, so (the patient) came here." The ED physician ordered a 12 lead EKG (diagnostic test of the heart's electrical activity) which was interpreted as normal, a CT scan of her abdomen and pelvis interpreted by the Radiologist as "No Acute Changes", and blood tests which revealed an elevation of the digestive enzymes (amylase and lipase). At 5:40 PM the ED physician arranged to transfer the patient to Hospital B and diagnosed her with acute pancreatitis. At 5:45 PM the ED physician documented on the transfer form the reason for transfer to Hospital B was "Higher level of Specialty Services Unavailable at this Facility:" and specified the specialty service unavailable was "Admission" . The ED physician documented on Hospital B's "Emergency Department Hospital Admission Orders" form that patient # 16 was stable, that she could be up at will, that her vital signs should be checked every 4 hours, then per policy, that her oral and IV fluid intake and urine output did not need to be measured, that she should not eat or drink anything, that the IV fluids should continue, that she could receive IV pain medication and medication to treat nausea, and that four blood tests should be obtained in the morning. All of these physician orders for inpatient care could have been provided at Parkland Health Center. Review of Hospital B's medical record revealed Patient # 6 was admitted as an inpatient sometime after 7:45 PM on 7/25/12 and was discharged at 11:20 AM on 7/27/12 for an inpatient stay of approximately 40 hours (within the 96 hour average length of stay limitation for CAHs).

9. Review of the medical record revealed Patient # 22 presented to the ED on 8/4/12 at 8:36 AM complaining of abdominal pain. The ED physician examined Patient # 22 and documented that she was in the ED yesterday with the same symptoms, was diagnosed with constipation, and had not had a bowel movement since leaving the ED. The ED physician ordered a CT scan of Patient # 22's abdomen along with multiple doses of an anti-anxiety medication and pain medication. At 1:15 PM the ED physician re-evaluated Patient # 22 and documented that her "pain (was) finally controlled." At 1:49 PM the CT scan of the patient's abdomen was completed and the findings were interpreted as normal. At 5:00 PM the ED physician documented contact with Hospital B who agreed to accept the transfer. The ED physician documented a final diagnosis of abdominal pain, constipation secondary to opiates (pain medication). At 5:05 PM the ED physician documented on the transfer form the reason for transfer to Hospital B was "Higher level of Specialty Services Unavailable at this Facility:" and specified the specialty service unavailable was "Admission". At 5:05 PM the ED physician documented on Hospital B's "Emergency Department Hospital Admission Orders" form that patient # 22 should be admitted as an outpatient for observation status (at Hospital B), that her condition was stable, that she required bed rest but could use the beside commode, that the nursing staff should check her vital signs (blood pressure, heart rate, respiratory rate, and temperature) every 4 hours for 24 hours, then per policy, that her oral and IV intake and urine output should be monitored and recorded every shift, and that her diet should consist of clear liquids. All of these physician orders for inpatient care could have been provided at Parkland Health Center. Review of Hospital B's medical record revealed Patient # 22 was admitted as an outpatient observation sometime after 5:00 PM on 8/5/12 and was discharged at 2:45 PM on 8/6/12, for a stay of less than 24 hours (within the 96 hour average length of stay limitation for CAHs).

10. During a telephone interview on 08/08/12 at 12:05 PM Staff H, ED physician stated that he never considered inpatient admission to the CAH.

11. During a telephone interview on 08/08/12 at 12:49 PM Staff L, Physician stated that he knew there were inpatient beds at the CAH but preferred to have his patients at the nearby Hospital B.

12. During a telephone interview on 08/08/12 at 1:30 PM Staff M, Hospitalist stated that he had been employed with the organization for three years and was not aware the CAH had inpatient bed capabilities.

13. During an interview on 08/09/12 at 9:48 AM Staff A stated the Medical Staff Bylaws, Rules and Regulations were approved and applied to the CAH.

Record review of the facility "Medical Staff Bylaws, Rules and Regulations, Article V Categories of Medical Staff, Section 5.2 Active Staff" revised and approved 12/20/12 showed the following direction:
-Paragraph c.4.A. Responsibilities, Each member of the Active Staff shall attend patients as follows, Physician, Dentists, Podiatrists, Psychologist members of the Active Staff shall participate in a call schedule, admit patients either in his/her own service or to another, round on patients, enter chart notes or orders, see in consultation, or perform procedures on at least 25 patients per year in the Hospital.
-Paragraph c.4.B Attend no less than 50% of the regular meetings of the Medical Staff, Division, and Committees of which the Practitioner is a member.
-The Medical Staff of the facility, as a separate, certified Critical Access Hospital, has failed to follow the requirements as set forth in the Medical Staff Bylaws, Rules and Regulations.

14. During an interview on 08/09/12 at 10:15 AM Staff A confirmed the following:
-She had never specifically told anyone that the CAH had inpatient care capabilities.
-Since the last survey she had not advertised in media (print or otherwise) that the CAH had inpatient care capabilities.
-She had not made any attempts to inform the community that there were inpatient bed capabilities because she did not feel that was required.













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