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Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure an effective governing body that is responsible for the conduct of the hospital. The facility failed to have an overall institutional plan and budget (Cross refer Tag A-0073), failed to maintain a contract for patient medical transport (Cross refer Tag A-0083), failed to maintain and have available diagnostic radiological services (Cross refer Tag A-0529), failed to ensure diagnostic services were available for patients presenting to the emergency department with a medical emergency (Patient (P) 2) (Cross Refer Tag A-1101), and failed to ensure oversight and direction of the respiratory care services department (Cross refer Tag A-1151). This failure resulted in three Immediate Jeopardy (IJ) situations, posing a serious risk of harm to patients.

Findings include:

On 3/7/24 at 3:28 PM, three IJ's were identified for the facility's failure to ensure the maintenance of a contract for patient medical transport for patients requiring diagnostic radiological services for both inpatient and in the emergency department, and for the failure of the facility to ensure the maintenance and availability of diagnostic radiological services for a patient with a medical emergency. On 3/7/24 at 5:40 PM, the three IJ templates were presented to administration and removal plans were requested. On 3/8/24 at 12:48 PM, an acceptable removal plan was received for the IJ corresponding to Tag A-0529. The facility implemented the following for this removal plan: Borrowed IV contrast from another local hospital for use at the facility until their shipment comes in; Confirmed the shipment order that was placed was changed to overnight shipping to ensure reception of the ordered contrast on 3/8/24; Re-education to radiologic staff and administration for the protocol for ordering supplies when they fall below par levels. A tour was conducted of the Radiology Department to confirm that education was received, the protocol for ordering was posted and visible to staff, and visual confirmation that the shipment of contrast dye had been received. The IJ for Tag A-0529 was resolved on 3/8/24 at 3:00 PM, after the State Survey Agency verified full implementation of the removal plan. On 3/13/24 at 1:45 PM, an acceptable removal plan was received for the IJ corresponding to Tag A-0083 and Tag A-1101. The facility implemented the following for this removal plan: Procured a transport contract with a local hospital to include medical transport for patients requiring services from the facility; a signed contract included the designation of an onsite ambulance to remain at the facility for BLS [Basic Life Support] transfers. In the event of need for ALS [Advanced Life Support] transport services, facility has plan to contact with a second ambulance provider for assistance with ALS transfer of patients on an as needed basis; and the education of Emergency Department (ED) staff of new transfer protocol. The IJ's for Tags A-0083 and Tag A-1101 were resolved on 3/14/24 at 3:45 PM, after the State Survey Agency verified full implementation of the removal plan.

Cross Reference:
482.12(c) - Contracted Services
482.12(d) - Institutional Plan and Budget
482.26 - Radiologic Services
482.55 - Emergency Services
482.57 - Respiratory Services

Based on staff interview, it was determined that the facility failed to have an overall institutional plan and budget.

Findings include:

On 3/14/24 at 12:11 PM, the facility's institutional plan and budget for the year 2023 and 2024 was requested from Staff (S) 1, Director of Quality and Informatics. S1 reviewed the federal guidelines in this surveyor's presence to ensure what was being asked. At 1:19 PM, S1 returned and introduced S16, interim Chief Financial Officer, to speak about the institutional plan and budget. S16 stated that the facility does not have a budget for the year 2024, but stated that the facility is following the "Go Forward Plan." S16 explained that the plan focuses on looking at what it looks like for the future of the facility and the focus is not on creating a budget but rather looking at the service lines at the facility. S16 stated that by looking at the service lines, the focus is on what is provided, what is needed and what is not needed. S16 stated that Senior leadership meet every other week to discuss. S16 was asked about an operational budget and expenses for the daily operations at the facility. S16 reconfirmed that there was no budget and stated, "when something is needed, that needs to be fixed, then we will deal with it." When asked to provide the Budget and institutional plan for the year 2023 for review, S1 and S16 stated the facility did not have one and confirmed that neither of them had seen a budget or plan for the year 2023. When asked to provide documentation of the "Go Forward Plan," S1 and S16 stated that it was not written down anywhere and could not provide evidence of the plan.

Based on staff interview, vendor interview, and review of facility documents, it was determined that the facility failed to ensure an effective services contract for patient medical transport for patients requiring medical care not available at the facility.

Findings include:

On 3/7/24, Patient (P) 2 presented to the facility Emergency Department (ED) at 8:32 AM for a complaint of dizziness, back pain, and palpitations. P2 required medical transport to a local hospital for Stat (Immediate) diagnostic radiologic services that were not available at the facility. The order was place for the Stat Computed Tomography (CT) Scan on 3/7/24 at 11:13 AM. An interview with Staff (S) 10, Medical Director of the ED, on 3/7/24 at 1:20 PM, was conducted. S10 indicated that he/she was still waiting for a transfer for P2. S10 stated that S13, Chief Nursing Officer, was made aware that a transfer was needed for P2 at 11:30 AM. When S10 was asked what was causing the delay, S10 stated that the transport service refused transfer due to non-payment. S10 stated that S13, was made aware, and that alternate means of transportation were being looked into and there was no approximate time for which the transfer may take place. S10 confirmed at this time that he/she had not been made aware of any downtime or scheduled downtime for any radiological services.

On 3/7/24 at 11:17 AM, S6, Radiologic Technologist, stated that there was scheduled preventative maintenance of the Computed Tomography (CT) scanner to start at approximately 12:00 PM until about 4:00 PM. S6 stated that S13 would have known about the scheduled maintenance and would have sent out a mass email to the facility's providers to let them know that the service would not be available.

On 3/7/24 at 1:59 PM, S13 confirmed that he/she would send notification to the facility's providers regarding scheduled downtime, or issues that would cause an interruption in service, such as lack on IV (Intravenous) contrast dye. S13 was asked for documentation of the notification to the facility's providers regarding the CT Scanner downtime. S13 was unable to provide this documentation, stating that it hadn't been sent yet. S12, Director of Operations, and S13 were asked if there had been issues with transport. S12 stated that issues with the transport service were recent, and the transport service has been resistant due to short staff and availability of crews. S12 and S13 confirmed that there was an issue the previous week where the contracted transport service refused a patient transfer to a local hospital. S12 states that the contracted service administration has different viewpoints on whether to accept or refuse transfer services from the facility. S12 stated that he/she is in the process of signing a contract with another transport company, but it has not been finalized yet.


49075


Upon request, S1, Director of Quality and Informatics and S13 provided the contract with [Transport Company A] for review. The contract, titled "Medical Transportation Service Agreement," dated March 1st, 2020, stated, "... Provider shall provide emergency and non-emergency medical transportation services to facility twenty-four hours a day, seven days a week, three hundred and sixty-five days a year."

A second contract with [Transport Company A] titled "Dedicated Lower Mode Van Agreement," dated March 8th, 2024, was provided by the S1 and S13. Upon review of this document, it was determined that the contract was not signed by the facility or the transportation provider.

S1 and S13 provided a third contract with [Transport Company B] titled "Dedicated Medical Transportation Services Agreement," effective February 23rd, 2024. This contract lacked signatures from the facility and Transport Company B. After reviewing the facilities transfer log, it was determined that there were no patient transfers completed by Transport Company B from December 2023 to March 2024.

On 3/7/24 at 3:03 PM, a call was made to the current contracted transport company to speak with the interim administrator, S19. S19 stated that the owner, S20, was on vacation and S19 was in charge at the moment. S19 stated that he/she refused a transfer today from the facility due to continued non-payment from the facility, and confirmed a refused transfer last week from the facility for the same reason. S19 stated that "it has been some time" since the facility has paid the invoices, and that the transport can't continue to offer services if they do not get paid. At 3:10 PM, a call was held with S20 of the transport company. S20 stated that he/she can't keep resources at the facility, an onsite ambulance, when the company is not getting paid. S20 stated that the last payment made by the facility was a couple of years ago. S20 states that he/she had received a text message from S12 on 3/6/24 that the facility's CT was going down, and then another text on 3/7/24 at 11:30 AM from S12 to confirm that S20 had received the message. S20 is on vacation and S19 was making the decisions at the transport company. S20 stated that he/she will let S19 know to not refuse services, as S20 does not want to "leave patients hanging when they need care". S20 restated that he/she would not leave an ambulance onsite at the facility waiting, but stated that the transport company would respond within 30 minutes for an emergent transfer. S20 stated that he/she was not aware a patient needed transfer this day and was refused.

Upon request, S1, provided the facility policy titled, "Emergency Management of Cerebrovascular (CVA) Patient," Reviewed July 2015. The policy stated, "... F. transport the patient for a non-contrast CT of the head. Door to CT Scan must be completed within 25 minutes. CT Scan must be interpreted within 20 minutes of completion ..." This policy was reviewed with S1 and S13 on 3/8/24 at 3:05 PM. When asked how the facility would ensure timely transport of a patient that presented with symptoms of stroke, either inpatient or to the emergency department, during CT downtime, S1 and S13 confirmed that if no ambulance was onsite, they could not ensure the timeliness of transport to CT Scan.

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to maintain and have available diagnostic radiologic services (Cross refer Tag A-0529), and the facility failed to ensure that a qualified staff member was appointed to the Director of Radiology position (Cross refer Tag A-0547). The failure to maintain and have available diagnostic radiological services (Tag A-0529) resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients.

Findings include:

On 3/7/24 at 3:28 PM, an IJ was identified for the facility's failure to ensure the maintenance and availability of diagnostic radiological services for a patient with a medical emergency. On 3/7/24 at 5:40 PM, the IJ template was presented to administration and a removal plan was requested. On 3/8/24 at 12:48 PM, an acceptable removal plan was received. The facility implemented the following for the removal plan: Borrowed IV (intravenous) contrast from another local hospital for use at the facility until their shipment comes in; Confirmed the shipment order that was placed was changed to overnight shipping to ensure reception of the ordered contrast on 3/8/24; Re-education to radiologic staff and administration for the protocol for ordering supplies when they fall below par levels. A tour was conducted of the Radiology Department to confirm that education was received, the protocol for ordering was posted and visible to staff, and visual confirmation that the shipment of contrast dye had been received. The IJ was resolved on 3/8/24 at 3:00 PM, after the State Survey Agency verified full implementation of the removal plan.

Cross Reference:
482.26(a) - Scope of Radiologic Services
482.26(c)(2) - Qualified Staff

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that an adequate supply of intravenous (IV) contrast dye needed for stat (immediate) diagnostic radiological exams for patients that present to the Emergency Department (ED) with a medical emergency, in three of three medical records reviewed (Patient (P) 2, P3, and P5.

Findings include:

On 3/7/24 at 10:40 AM, when asked about supply and staffing issues in the Radiology Department, Staff (S) 10, ED Medical Director, stated that he/she was not aware of any downtime in radiology recently, but was aware that the department was short on contrast dye "last week." S10 then stated that he/she was just made aware that the facility was completely without IV contrast "about two hours ago." When S10 was asked how he/she was notified, S10 responded that he/she had found out when he/she had placed an order for a Computed Tomography (CT) Scan with contrast and called to follow-up on the exam.

A tour was conducted of the Radiology Department on 3/7/24 at 11:07 AM. S6, Radiologic Technologist, stated that there was no contrast to do CT scans if needed. S6 stated that he/she was made aware on 3/6/24 at 4:00 PM by the previous day's technician that there would not be enough contrast for 3/7/24. S6 stated that he/she was told that S13, Chief Nursing Officer (CNO), was made aware of the low supply, but S6 was unaware of any follow-up to the issue. S6 stated that he/she was unsure of why the contrast dye had run out and that this surveyor would need to speak with someone in the facility's purchasing department.

Four orders for STAT CT scans with contrast were observed on the desk of CT technician's monitor room for Patient (P) 2, P3, P5, and P11. S6 stated that P11 was too unstable to come for CT scan and was waiting to hear from the inpatient unit for when the patient may be ready. P2, P3, and P5 were patient's in the ED. S6 stated that P3 and P5's providers were notified of the contrast supply issue, and new orders for P3 and P5 were received to perform the CT's without contrast. At 11:30 AM, S6 took a phone call, with this surveyor present, from P2's ED provider. P2's provider was inquiring the status of the availability of the contrast dye. S6 responded that the facility still was without dye and S6 was unsure of when a new supply would be available. Upon request to S1, the medical records of P2, P3, and P5 were provided for review.

P2 presented to the ED on 3/7/24 at 8:32 AM with complaints of dizziness, back pain, and palpitations. P2's order for the CT of the Chest with contrast to rule out (r/o) a Pulmonary Embolism (PE, clot in the lung) was placed on 3/7/24 at 11:13 AM. An interview with S10 on 3/7/24 at 1:20 PM, noted that S10 was still waiting for a transfer for P2. During the time of this interview, S10 noted that P2's lab had resulted, thus changing the treatment plan for the patient. S10 confirmed that the suspicion was lower for a PE and the labs pointed toward a thyroid issue instead. The order for the Stat CT of the chest with contrast was discontinued at 1:29 PM. The time between the Stat CT order and it's discontinuation was 2 hours and 16 minutes. P2 was admitted for observation and had bilateral lower extremity ultrasounds ordered instead.

P3 had an order for a Stat CT of the Abdomen/Pelvis with contrast placed on 3/7/24 at 7:20 AM. The medical record lacked evidence of an order to transfer the patient out to have the test completed. At 11:35 AM, the order was changed to Stat CT Abdomen/Pelvis without contrast. The scan was conducted at 11:51 AM. The time between the Stat order with contrast and the order change was 4 hours and 15 minutes. These findings were confirmed with S13 on 3/8/24 at 4:01 PM.

P5 had simultaneous orders for a CT Head/Neck and a CT Angio of the Head/Neck placed on 3/7/24 at 9:39 AM for r/o Stroke. The medical record lacked evidence of an order to transfer the patient out to have the test completed. P5's order for the CT Angio Head/Neck was discontinued at 11:21 AM. The CT was not completed within 25 minutes in accordance with the facility stroke policy. The time between the Stat order and the discontinuation of the order was 1 hour and 42 minutes. Review of P5's medical record revealed that the patient had a history of seizures and was post-ictal (a period of time that begins when a seizure subsides and ends when the patient returns to baseline) from a seizure upon arrival to the ED, therefore the CT Angio Head/Neck was not indicated at that time. This finding was confirmed with S10, Medical Director of the ED, at the time of discovery. P5 was admitted to the facility.

On 3/7/24 at 12:48 PM, and interview was conducted with S11, Purchasing Manager. S11 explained the process for ordering supplies when they are below par levels. S11 stated that the technician in the department monitors the departments supplies, if a certain supply falls below par level then the technician enters an order for the supply. This order, called a purchase order, is then reviewed by the purchasing department. If the order is okay, then the order is sent to the vendor. When asked the last time IV contrast dye was ordered, S11 stated sometime this week. S11 confirmed that there was an issue with credit and the order had been put on hold but has now been shipped. S11 stated that the order was shipped yesterday but was unsure of the date of delivery to the facility. Upon request, the purchase order and correspondence with the vendor was provided for review. The order was dated March 4, 2024, but was noted that the order was not released until 3/5/24 with a request for payment details.

On 3/7/24 at 2:10 PM, when asked if he/she was aware when the IV contrast had run out, S13 stated "Sometime today." S13 stated that he/she was aware on Monday (3/4/24) that the facility was running low and S13 followed-up with the finance department to determine the hold up. S13 stated that a second order for IV contrast was placed on Monday (3/4/24) "sometime after noon." S13 stated that he/she was made aware on 3/6/24 at 4:00 PM by the CT technologist that there was only one bottle of contrast remaining. When ask what guidance was given to staff regarding this low supply, S13 stated that he/she told the CT technologist to let him/her know when they ran out. S13 confirmed that a memo to notify all physicians at the facility that there was no contrast dye was not drafted or sent out. S13 also stated that he/she was unsure of when the shipment would be coming in. S13 confirmed that diagnostic radiologic exams requiring contrast dye would not be able to be performed at the facility at this time. S13 stated that those patients would have to be transferred out to have those tests completed.

P2, P3, and P5 did not have the ordered CT with contrast due to lack of contrast availability. The facility was without contrast for CT scans until 4:00 PM. At 4:39 PM, upon visual verification of the contrast dye, S1 confirmed that the contrast dye had arrived at 4:00 PM, as it had been borrowed and just delivered from a local hospital.

Facility policy titled, "[Facility Name] Radiology Internal Escalation Policy," Effective December 12, 2018, stated, "... Delay - Exams are expected to complete the workflow, Ordered to Final, within the following time frames. Anything outside of these ranges is considered a delay. -STAT - 1 hour ...".

Facility policy, titled, "Emergency Management of Cerebrovascular Accident (CVA) Patients," Reviewed - July 2015, stated, "... F. ... Door to CT scan must be completed within 25 minutes. CT scan must be interpreted within 20 minutes of completion ..."

Based on staff interview and review of facility documents, it was determined that the facility failed to ensure that a qualified staff member was appointed to the Director of Radiology position.

Findings include:

On 3/7/24 at 9:33 AM, Staff (S) 1, Director of Quality and Informatics, stated that the Director of the Radiology Department left the position about two weeks ago, and that S13, Chief Nursing Officer, was filling the position in the interim.

The job description for the Director of Radiology was requested along with S13's personnel file. On 3/8/24 at 11:43 AM, the documents were provided for review. The job description for the Director of Radiology stated, "...Director Diagnostic Imaging and Cardiovascular Services ... The minimum education and certification ... requires a bachelor's degree in Radiology or Business Administration, he/she must be certified by the American Registry of Radiological Technologies or possess another preferred radiological certification ..." Upon review of the personnel file for S13, the file lacked evidence of education and training required for the position of the Director of Radiology.


49075


This finding was shared with S13 on 3/8/24 at 4:01 PM, in the presence of S1. S13 confirmed that he/she was not qualified for the position. S1 stated that it has been hard to fill the gaps and that the facility was still trying to find an Administrator Consultant to assist at the facility.

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that the emergency needs of patients are met. The failure to maintain and have available diagnostic radiological services and to maintain a contract for patient medical transport for an Emergency Department patient with a medical emergency (Cross refer Tag A-1101) resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients.

Findings include:

On 3/7/24 at 3:28 PM, an IJ was identified for the facility's failure to maintain and have available diagnostic radiological services and to maintain a contract for patient medical transport for an Emergency Department patient with a medical emergency. On 3/7/24 at 5:40 PM, the IJ template was presented to administration and a removal plan was requested. On 3/13/24 at 1:45 PM, an acceptable removal plan was received for the IJ (Tag A-1101). The facility implemented the following for this removal plan: Procured a transport contract with a local hospital to include medical transport for patients requiring services from the facility; a signed contract included the designation of an onsite ambulance to remain at the facility for BLS [Basic Life Support] transfers. In the event of need for ALS [Advanced Life Support] transport services, facility has plan to contact with a second ambulance provider for assistance with ALS transfer of patients on an as needed basis; and the education of Emergency Department (ED) staff of new transfer protocol. The IJ was resolved on 3/14/24 at 3:45 PM, after the State Survey Agency verified full implementation of the removal plan.

Cross Reference:
482.55(a) - Organization and Direction
482.55 (a)(2) - Integration of Services

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to provide critical care transport for a patient that needed a diagnostic radiological exam, that could not be completed at the facility to rule out a medical emergency, in one of one medical record reviewed (Patient (P)2).

Findings include:

P2 presented to the Emergency Department (ED) on 3/7/24 at 8:32 AM with a complaint of dizziness, back pain, and palpitations. P2 was triaged at 8:40 AM as a level 3 urgent. Vital signs were taken indicating the patient's heart rate was abnormal above 100 beats per minute. Lab (laboratory) work was sent which resulted in an elevated D-Dimer test, and an order for a CT with contrast to rule out (r/o) a Pulmonary Embolism (PE, clot in the lung) was placed at 11:13 AM. At 11:30 AM, P2's ED provider was made aware that the facility still did not have contrast dye needed to perform the diagnostic study. An interview with S10 on 3/7/24 at 1:20 PM, noted that S10 was still waiting for a transfer for P2. When S10 was asked what was causing the delay, S10 stated that the transport service refused transfer due to non-payment. S10 stated that S13, Chief Nursing Officer, was made aware, and that alternate means of transportation were being looked into.

On 3/7/24 at 1:59 PM, S13 confirmed that he/she would send notification to the facility's providers regarding scheduled downtime or for any issues that would cause and interruption in service, such as lack of IV contrast dye. S13 was asked for documentation of the notification to the facility's providers regarding the CT Scanner downtime and/ or the lack of contrast dye, S13 was unable to provide this documentation, stating that it hadn't been sent yet. S12, Director of Operations, and S13 were asked if there had been issues with transport. S12 stated that issues with the transport service were recent, and the transport service has been resistant due to short staff and availability of crews. S12 and S13 confirmed that there was an issue the previous week where the contracted transport service refused a patient transfer to a local hospital. This was unable to be confirmed by surveyors. S12 states that the contracted service administration has different viewpoints on whether to accept or refuse transfer services from the facility. S12 stated that he/she is in the process of signing a contract with another transport company, but it has not been finalized yet.

Upon request, S1 and S13 provided the contract with [Transport Company A] for review. The contract, titled "Medical Transportation Service Agreement", dated March 1st, 2020, stated, "... Provider shall provide emergency and non-emergency medical transportation services to facility twenty-four hours a day, seven days a week, three hundred and sixty-five days a year."

A second contract with [Transport Company A] titled "Dedicated Lower Mode Van Agreement," dated March 8th, 2024, was provided by the S1 and S13. Upon review of this document, it was determined that the contract was not signed by the facility or the transportation provider.

S1 and S13 provided a third contract with [Transport Company B] titled "Dedicated Medical Transportation Services Agreement," effective February 23rd, 2024. This contract lacked signatures from the facility and Transport Company B. After reviewing the facilities transfer log, it was determined that there were no patient transfers completed by Transport Company B from December 2023 to March 2024.

On 3/7/24 at 3:03 PM, a call was made to the current contracted transport company to speak with the interim administrator, S19. S19 stated that the owner, S20, was on vacation and S19 was in charge at the moment. S19 stated that he/she refused a transfer today from the facility due to continued non-payment from the facility and confirmed a refused transfer last week from the facility for the same reason. S19 stated that "it has been some time" since the facility has paid the invoices, and that the transport can't continue to offer services if they do not get paid. At 3:10 PM, a call was held with S20 of the transport company. S20 stated that he/she can't keep resources at the facility, an onsite ambulance, when the company is not getting paid. S20 stated that the last payment made by the facility was a couple of years ago. S20 states that he/she had received a text message from S12 on 3/6/24 that the facility's CT was going down, and then another text on 3/7/24 at 11:30 AM from S12 to confirm that S20 had received the message. S20 is on vacation and S19 was making the decisions at the transport company. S20 stated that he will let S19 know to not refuse services, as S20 does not want to "leave patients hanging when they need care." S20 restated that he/she would not leave an ambulance onsite at the facility waiting but stated that the transport company would respond within 30 minutes for an emergent transfer. S20 stated that he/she was not aware a patient needed transfer this day and was refused.


49075

Based on staff interview and review of facility documents, it was determined that the facility failed to ensure oversight and direction of the respiratory care services department.

Findings include:

The facility failed to ensure there was a qualified director of respiratory care services (Cross refer to Tag A-1153).

Cross Reference:
482.57(a)(1) - Director of Respiratory Care

Based on staff interview and review of facility documents, it was determined that the facility failed to ensure that there was a Director of Respiratory Care services who is a doctor of medicine or osteopathy.

Findings include:

On 3/14/24 at 11:36 AM, Staff (S) 1, Director of Quality and Informatics, when asked who the director of respiratory services was, stated that the facility does not have a director, but has a manager, S18. The personnel file for S18 was requested for review. Upon review of the personnel file, S18 was noted to have a job description that stated, "Lead Respiratory Therapist" and was signed by the department manager on 1/23/15 and by the human resources executive on 1/27/15. The personnel file lacked evidence that S18 was a Doctor of Medicine or osteopathy. This finding was shared with S1 at the time of discovery.

S1 provided a list of position vacancies for the facility. This list was reviewed and did not include an open position for a director of respiratory care services. This finding was shared with S1 at the time of discovery. When asked, S1 stated that he/she would look into it. On 3/14/24 at 2:17 PM, the job description for director of respiratory care services was requested for review. The facility was unable to provide a copy of this job description.