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Based on record review, observation, staff interview, review of respiratory therapy (RT) schedules, review of an emergency room (ER) diversion list, review of the facility's Scope of Practice, and review of Section 1820 of the Social Security Act, the hospital failed to be primarily engaged to maintain the requirements to function as a Critical Access Hospital. The hospital failed to provide acute care inpatient beds for a period that does not exceed, as determined on an annual, average basis, 96 hours per patient. The hospital also failed to to have the ER available to all community patients due to not having RT on duty. This affected six patients (#3, #6, #7, #8,#9, and #10), who presented to the emergency room and required hospital admission, and had the potential to affect any patients who presented to the emergency room or received any outpatient surgical procedure.

Findings include:

Review of the Section 1820 of the Social Security Act revealed under 1820 (B): Criteria for Designation as Critical Access Hospital, Section (2) (ii): makes available 24-hour emergency care services. Criteria at Section (2)(iii): provides not more than 25 acute care inpatient beds (meeting such standards as the Secretary may establish) for providing inpatient care for a period that does not exceed, as determined on an annual, average basis, 96 hours per patient.

1) Interview during the entrance conference on 04/11/24 with the Interim Chief Executive Officer, Staff A, revealed the hospital's inpatient unit was currently closed. Staff A stated this unit was closed in December 2023 due to many physicians leaving this facility.

Observations during a tour of the hospital on 04/11/24 at 2:45 PM, with the Vice President of Admitting Services (Staff G), revealed the medical surgical department had eighteen rooms with the capacity of 20 patients. There were no patients currently on the unit. Interview at this time with Staff G revealed the unit closed in December 2023. Continued observation revealed a surgical unit.

Review of the Discharge Report revealed a patient was discharged on 09/28/23 with no patients admitted to the hospital until 12/11/23, when two patients were admitted. The last patient was discharged on 12/14/23 with no further patients admitted to the hospital.

Review of the medical record revealed Patient #7 came to the ER on 10/12/23 at 12:55 AM with complaints of nausea and vomiting with abdominal pain for the past six hours. Computerized Tomography (CT) scan of the abdomen showed a small hiatal hernia, gallbladder wall thickening and a stone with concern for acute cholecystitis. Physician orders were received to transfer the patient for inpatient care. The patient was transferred to another hospital at 8:40 AM.

Review of the medical record revealed Patient #6 came to the ER by squad on 11/04/23 at 5:29 PM with increased confusion and fever. Following an assessment and work up, orders were received to transfer the patient for inpatient care. Patient #6 was transferred to another hospital on 11/05/23 at 1:32 AM.

Review of the medical record revealed Patient #10 presented to the hospital on 11/14/23 at 8:50 PM after a fall at home and shaking. After an assessment and work up, orders were received to transfer the patient to another hospital for inpatient care. Patient #10 was transferred to another hospital at 3:00 AM.

Review of the medical record revealed Patient #3 presented to the emergency room (ER) by squad on 01/27/24 at 2:16 PM with shortness of breath (SOB) and history of congested heart failure (CHF). Patient #3 was on six liters of oxygen. Orders were received from the ER physician to transfer the patient to another hospital due to increasing oxygen needs and need for inpatient services. Patient #3 was transferred to another hospital on 01/28/24 at 12:40 PM.

Review of the medical record revealed Patient #8 presented to the ER on 02/10/24 at 11:20 AM with abdominal pain and complaints of nausea and vomiting. Physician orders were received to start an intravenous of normal saline (NS) and obtain blood work. Initial glucose level was 393 and insulin and a NS fluid bolus were given. Orders were received to transfer this patient to another hospital for inpatient care. Patient #8 was transferred to another hospital on 02/11/24 at 5:15 AM.

Review of the medical record revealed Patient #9 was a three year old who presented to the ER on 02/25/24 at 6:47 PM with her parents after a fall from a chair, which was not witnessed. Initial vital signs included a temperature of 97.9 degrees Fahrenheit. At 10:49 PM, the temperature had increased to 100.6 degrees Fahrenheit. At 10:00 PM the family requested that the patient be observed overnight. The patient was transferred to another hospital for inpatient care on 02/26/24 at 3:20 AM.

Interview with Staff A and Staff K on 04/15/24 at 5:00 PM confirmed the hospital was not providing acute inpatient care services. They also verified Patient #3, Patient #8 and Patient #9, who presented in the ER, had to be transferred to another hospital to be admitted for care.

2) Interview with Staff J, who was the ER Manager at the time of the interview, on 04/11/24 at 10:40 AM, revealed the hospital has had to put the ER on diversion at times for emergency medical systems (EMS) due to not having a respiratory therapy in house.

Interview with the RT Manager on 04/11/24 revealed RT are not in house 24/7. They are scheduled Monday through Friday all three shifts and every other weekend from 7:00 AM-7:00 PM, otherwise the ER physician takes care of things.

Review of the dates EMS was diverted from bringing patients to the ER from 01/01/24 through 04/15/24 included one day in January, sixteen shifts in February, twenty-six shifts in March, and seven shifts thus far in April.

Review of the RT projected shifts schedule for the remaining days of April, May and June, 2024 revealed dates when no therapist was scheduled for this hospital.

Review of the facility's Scope of Service listed the emergency room is open 24 hours a day seven days a week. Respiratory Therapy are available in house or on call 24 hours a day/seven days a week.

Interview with Staff A on 04/15/24 at 4:45 PM verified the findings of not having RT in-house and needing to put the ER on diversion for EMS services.

Based on observation, record review, and staff interview, the facility failed to meet the applicable provisions in accordance with the Life Safety Code (NFPA 101) to ensure the fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire (K343)(K711), failed to ensure Fire Watch Policy was being implemented (K346), and failed to ensure accurate documentation of fire drills were recorded (K712). The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient safety needs would be met. (C930)

Based on observation, record review, and staff interview, the facility failed to meet the applicable provisions in accordance with the Life Safety Code (NFPA 101) to ensure the fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire, failed to ensure Fire Watch Policy was being implemented, and failed to ensure accurate documentation of fire drills were recorded. These deficient practices had the potential to affect an isolated number residents and an indeterminate number of staff.

Findings include:

1) Observation during facility tour with the Director of Maintenance (DM) on 04/12/24 between 11:35 A.M. and 12:15 P.M. noted the fire alarm system did not transmit to the monitoring company. The fire alarm system had the contractor on site during the survey changing the dialer from two dedicated phone lines to an internet and cell phone based dialer. The fire alarm was tested at 12:05 P.M. to verify it functioned with the notification devices and release of door hold opens. No issues were noted with the local function.

Interview with the DM verified the finding at the time of observation. Further interview found that the previous fire alarm monitoring company had discontinued service due to non payment in June of 2023 and the alarm has been a local only since then.

Interview with the Fire Alarm Contractor (FAC) verified that the panel currently will not call the fire department. Further interview found the company has been hired to provide monitoring services and the system will be able to transmit and notify emergency services after completion of his installation.

2) During the record review on 04/12/24 at 11:10 A.M. with the DM it was found there was no documentation of a fire watch being conducted. The facility had no documentation verifying the staff knew the fire alarm was still out of service or that a verified responsible on site person would call 911 during a fire alarm.


Interview with the DM verified the finding at the time of review. The DM stated an email went out in June to all users that they had to call 911 during a fire alarm. When asked if it was documented who specifically would be responsible for that call and that a log was being maintained to verify the responsibility was passed on at the end of shift the DM stated "That is not happening."

3) Review of the fire alarm drill sheets from June 2023 until March 2024 did not contain factual or accurate information. The supervisory signal received section had times of alarm transmittal and receipt, even though there was no monitoring company actively receiving the signals. The comments section failed to identify the requirement of an on-site dedicated individual calling 911 or verifying emergency service would be notified.

Interview with the Director of Maintenance verified the finding at the time of review.

Based on medical record review, staff interview, review of the Discharge Report, review of the facility's Scope of Service, observation, review of emergency room (ER) diversion list, and review of respiratory therapy schedules, the facility failed to have the needed cleaning solution to ensure diagnostic endoscopy procedures could be performed (C1024), failed to provide inpatient services (C1026), failed to have the emergency room (ER) available to all community patients due to not having a RT on duty (C132), and failed to have an individual who was responsible for nursing services (C146). The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient care needs would be met.

Based on observation, staff interview, and review of the facility's Scope of Service, the facility failed to have the needed cleaning solution to ensure diagnostic endoscopy procedures could be performed. This has the potential to affect all patients scheduled for upper and lower endoscopy procedures.

Findings include:

A tour of the facility on 04/11/24 revealed a procedure room in the surgical area with a scope processing room which had an Olympus cleaning machine. Interview at this time with Staff J revealed the procedure room was for Endoscopy procedures.

Interview with Staff J, who was the current Surgery Manager, Emergency Room Manager and Interim Chief Nursing Officer (CNO) at the time of the interview, on 04/11/24 at 8:40 PM revealed the hospital is on a credit hold with many vendors. Staff J stated they have had trouble purchasing the endoscopy cleaning solution for the scopes. Staff J further stated the hospital they recently borrowed the solution from another hospital, but Staff J was unsure what they would do when this cleaning solution was gone.

Interview with Staff P on 4/15/24 at 9:40 AM revealed the hospital had five endoscopy procedures scheduled for 04/16/24 that were canceled due to not having the cleaning solution for the scopes. Interview further verified all of the patients were contacted on Friday, 04/12/24.

Review of the facility's Scope of Services under financial services revealed the statement, "ensuring resources are available to acquire goods and services is an essential part of patient care."

Interview with Staff A on 04/15/24 at 4:30 PM verified the hospital did not have the needed cleaning solution for the scopes to ensure the diagnostic endoscopies were able to be performed.

Based on record review, observation, review of discharge reports, and staff interview, the hospital failed to provide inpatient services. This affected six patients (Patients #3, #6, #7, #8,#9, and #10) who presented to the emergency room and required hospital admission, and had the potential to affect any patients who presented to the emergency room or received any outpatient surgical procedure.

Findings include:

Interview with the Interim Chief Executive Officer, Staff A, during the entrance conference on 04/11/24 revealed the hospital's inpatient unit was currently closed. Staff A stated this unit was closed in December 2023 due to many physicians leaving this facility.

Observations during a tour of the hospital on 04/11/24 at 2:45 PM, with the Vice President of Admitting Services (Staff G), revealed the medical surgical department had eighteen rooms with the capacity of 20 patients. There were no patients currently on the unit. Interview with Staff G at that time revealed the unit was closed in December 2023. Continued observation revealed a surgical unit.

Review of the discharge report revealed a patient was discharged on 09/28/23 with no patients admitted to the hospital until 12/11/23, when two patients were admitted. The last patient was discharged on 12/14/23 with no further patients admitted to the hospital.

Review of the medical record revealed Patient #7 came to the ER on 10/12/23 at 12:55 AM with complaints of nausea and vomiting with abdominal pain for the past six hours. Computerized Tomography (CT) scan of the abdomen showed a small hiatal hernia, gallbladder wall thickening and a stone with concern for acute cholecystitis. Physician orders were received to transfer the patient for inpatient care. The patient was transferred to another hospital at 8:40 AM.

Review of the medical record revealed Patient #6 came to the ER by squad on 11/04/23 at 5:29 PM with increased confusion and fever. Following an assessment and work up, orders were received to transfer the patient for inpatient care. Patient #6 was transferred to another hospital on 11/05/23 at 1:32 AM.

Review of the medical record revealed Patient #10 presented to the hospital on 11/14/23 at 8:50 PM after a fall at home and shaking. After an assessment and work up, orders were received to transfer the patient to another hospital for inpatient care. Patient #10 was transferred to another hospital at 3:00 AM.

Review of the medical record revealed Patient #3 presented to the emergency room (ER) by squad on 01/27/24 at 2:16 PM with shortness of breath (SOB) and history of congested heart failure (CHF). Patient #3 was on six liters of oxygen. Orders were received from the ER physician to transfer the patient to another hospital due to increasing oxygen needs and need for inpatient services. Patient #3 was transferred to another hospital on 01/28/24 at 12:40 PM.

Review of the medical record revealed Patient #8 presented to the ER on 02/10/24 at 11:20 AM with abdominal pain and complaints of nausea and vomiting. Physician orders were received to start an intravenous of normal saline (NS) and obtain blood work. Initial glucose level was 393 and insulin and a NS fluid bolus were given. Orders were received to transfer this patient to another hospital for inpatient care. Patient #8 was transferred to another hospital on 02/11/24 at 5:15 AM.

Review of the medical record revealed Patient #9 was a three year old who presented to the ER on 02/25/24 at 6:47 PM with her parents after a fall from a chair, which was not witnessed. Initial vital signs included a temperature of 97.9 degrees Fahrenheit. At 10:49 PM, the temperature had increased to 100.6 degrees Fahrenheit. At 10:00 PM the family requested that the patient be observed overnight. The patient was transferred to another hospital for inpatient care on 02/26/24 at 3:20 AM.

Interview with Staff A and Staff K on 04/15/24 at 5:00 PM confirmed the hospital was not providing acute inpatient care services. They also verified Patient #3, Patient #6, Patient #7, Patient #8, Patient #9, and Patient #10, who presented in the ER, had to be transferred to another hospital to be admitted for care.

Based on staff interview, review of emergency room (ER) diversion dates, review of respiratory therapy (RT) schedules, and review of the facility's Scope of Service, the facility failed to have the emergency room (ER) available to all community patients due to not having a RT on duty. This has the potential to affect all patients cared for in the ER.

Findings include:

Interview with Staff J, who was the ER Manager at the time of the interview, on 04/11/24 at 10:40 AM, revealed the hospital has had to put the ER on diversion at times for emergency medical systems (EMS) due to not having a respiratory therapy in house.

Interview with the RT Manager on 04/11/24 revealed RT are not in house 24/7. They are scheduled Monday through Friday all three shifts and every other weekend from 7:00 AM-7:00 PM, otherwise the ER physician takes care of things.

Review of the dates EMS was diverted from bringing patients to the ER from 01/01/24 through 04/15/24 included one day in January, sixteen shifts in February, twenty-six shifts in March, and seven shifts thus far in April.

Review of the RT projected shifts schedule for the remaining days of April, May and June, 2024 revealed dates when no therapist was scheduled for this hospital.

Review of the facility's Scope of Service listed the emergency room is open 24 hours a day seven days a week. Respiratory Therapy are available in house or on call 24 hours a day/seven days a week.

Interview with Staff A on 04/15/24 at 4:45 PM verified the findings of not having RT in-house and needing to put the ER on diversion for EMS services.

Based on a review of the facility's Scope of Service and staff interview, the facility failed to have an individual who was responsible for nursing services. This has the potential to affect all patients cared for at this facility.

Findings include:

Interview with Staff J, who was the manager of the emergency room (ER), operating room (OR) and Interim Chief Nursing Officer (CNO) at the time of the interview, on 04/11/24 at 10:40 AM revealed her last day of employment at the hospital was 04/12/24 due to many ongoing issues. Staff J stated she was asked to be the manager in October 2023 but did not feel qualified to be the manager.

Observations on 04/15/24 throughout the day revealed no CNO was present during the survey.

Review of the facility's Scope of Service, under administration staffing requirements for the department, revealed the hospital was to have a skill mix to include Chief Executive Officer, VP Patient Services, Chief Nursing Officer, and Chief Financial Officer.

Interview with Staff A on 04/15/24 at 4:45 PM revealed the facility did not have an individual responsible for nursing services as of 04/12/24.