HospitalInspections.org

Based on Staff interview and administrative document review the hospital failed to provide 24 hour nursing services when the facility closed and was not providing inpatient services on days when census reached zero.

The cumulative effect of this systemic failure resulted in facility non-compliance with the Condition of Participation for Nursing Services.

Based on Staff interview and administrative document review the hospital failed to provide 24 hour nursing services when the facility closed and was not providing inpatient services on days when census reached zero.

This failure resulted in the facility not providing 24-hour nursing services.

Findings:
On 11/2/2017 at 12:56 p.m., during an interview, in response to a question related to the posted hours for the facility, the Director of Nursing Services (DON) stated they are lobby hours. Patients can still have visitors but they need to be buzzed in. The DON was asked about weekends that the facility closed. The DON stated there was a nurse on call when there are no inpatients in case a discharged patient has any questions or concerns. The calls initially went to an answering service. The service notified the on-call nurse, and the nurse contacted the patient. If the concern was out of the nurse's scope of practice, the patient was instructed to contact the physician or call 911.

On 11/2/17 at 3:40 p.m., during an interview, the DON stated if a patient had to return to the operating room when there were no inpatients present, "that would be handled here." She stated the hospital had not needed to be reopened for a patient to return to the operating room since she had been hired on 9/6/16.

On 11/7/2017 at 11:54 a.m., during an interview, the Governing Body Chairman (GBC) stated the facility closes when there are no inpatients. He stated there are very few cases when they are closed all weekend. If they close it is usually on Sunday. He stated to his knowledge the closures were never discussed with the Governing Body. He also stated the impact of closing on the facility's licensure as a hospital was never discussed at the board meeting. When asked about the scheduling of surgeries the GBC stated the bulk of surgeries are done earlier in the week. He stated there were no policies which dictate the timing of the surgeries. The GBC stated the Board is aware of the Survey & Certification memo 17-44. He stated the facility's volume is an issue.

A review of the Facility's inpatient census for the period 9/30/17 to 10/31/17 indicated the facility was closed and no staff present on the following dates: 9/30/17, 10/1/17, 10/7/17, 10/8/17, 10/15/17, 10/21/17, 10/22/17, and 10/29/17.