HospitalInspections.org

Based on review of Medical Staff Rules and Regulations, review of facility policy, review of Emergency Department (ED) physician schedule, review of ED log (list of ED patients), review of a Health Alert Network (Public Health's notification system for rapidly disseminating alerts, updates and advisories to local, state and federal partners) report, review of an ED Diversion (redirected patients) log, observations and interviews, the facility failed to provide emergency services 24 hours a day/7 days a week (24/7) and failed to provide physician coverage in the ED.

The findings include:

The facility failed to ensure 24/7 availability of a physician or midlevel provider (physician assistant or nurse practitioner) in the ED, to provide medical treatment for patients presenting to the ED, and failed to provide 24/7 emergency services. The ED went on diversion on 1/22/2024 at 12:00 AM-1/24/2024 due to no physician available to provide coverage for the ED. Sixteen patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) presented to the ED, then were turned away without receiving treatment because no ED physician was available.

Refer to C-0882 and C-0894.

Based on review of facility policy, review of the Emergency Department (ED) log (list of ED patients), review of a Health Alert Network (Public Health's notification system for rapidly disseminating alerts, updates and advisories to local, state, and federal partners) report, review of an ED Diversion log (list of redirected patients), observations and interviews, the facility failed to provide emergency services 24 hours a day/7 days a week (24/7) affecting 16 patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) of 16 patients who presented to the ED from 1/22/2024-1/24/2024.

The findings include:

Review of the facility's policy "Scope of Services" revised 8/23/2021 showed, "...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel...Any patient presenting to the Emergency Department for care will be evaluated and treated...All services provided by [named facility] will be evaluated on an ongoing basis to ensure the needs of the patients and community are being met to the highest capabilities of the facility..."

Review of the ED log for 1/1/2024-1/24/2024 showed the last patient listed on the ED log arrived on 1/21/2024 at 10:00 PM and was discharged on 1/21/2024 at 11:45 PM. Review showed patients listed on the ED Diversion Log were not on the ED Log.

Review of a Health Alert Network report showed the facility went on diversion status on 1/21/2024 at 11:21 PM. The report showed the facility was on diversion due to no physician and Emergency Medical Services should transport patients to an alternate appropriate destination.

Review of a facility handwritten document titled "Diversion Log" showed 16 patients listed by number (no patient names included)presented to the ED seeking treatment as follows:
*Patient #1 arrived on 1/21/2024 at 11:30 PM with complaint of (c/o)
neck pain.
*Patient #2 arrived on 1/22/2024 at 1:30 AM with c/o high fever.
*Patient #3 arrived on 1/22/2024 at 3:00 AM with c/o possible kidney
stone.
*Patient #4 arrived on 1/22/2024 at 9:04 AM with c/o panic attack.
*Patient #5 arrived on 1/22/2024 at 9:26 AM with c/o fall.
*Patient #6 arrived on 1/22/2024 at 11:56 AM with c/o head laceration
(wound).
*Patient #7 arrived on 1/22/2024 at 12:04 PM with c/o wrist pain.
*Patient #8 arrived on 1/22/2024 at 2:55 PM with c/o cough/not feeling
well.
*Patient #9 arrived on 1/22/2024 at 3:10 PM with c/o psychiatric
evaluation
*Patient #10 arrived on 1/22/2024 at 3:55 PM with c/o fall.
*Patient #11 arrived on 1/22/2024 at 4:19 PM with c/o chest pain.
*Patient #12 arrived on 1/22/2024 at 9:23 PM with c/o intoxication.
*Patient #13 arrived on 1/23/2024 at 7:00 AM with c/o wrist pain.
*Patient #14 arrived on 1/23/2024 at 2:01 PM and asked for a
wheelchair.
*Patient #15 arrived on 1/23/2024 at 8:30 PM with c/o nausea and
vomiting.
*Patient #16 arrived on 1/23/2024 at 9:45 PM with c/o shortness of
breath and chest pain. Staff called 911 for the patient.

Observation of the facility's main entrance on 1/24/2024 at 9:45 AM showed a sign was posted stating the ED was on diversion.

During an interview on 1/24/2024 at 9:56 AM, the Chief Nursing Officer confirmed the ED was on diversion and confirmed the ED was not receiving patients.

Observation of the ED on 1/24/2024 at 10:09 AM showed a sign stating the ED was on diversion posted at the ED entrance from within the facility and the ED main entrance. The ED was staffed with 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN). No physician or midlevel provider (physician assistant or nurse practitioner) were in the ED. There were no patients observed in the ED.

During an interview on 1/24/2024 at 10:18 AM, ED Registration Clerk #1 confirmed the ED had been on diversion since Sunday night (1/21/2024) and the ED was not receiving patients. ED Registration Clerk #1 stated patients who presented to the ED were told the ED was on diversion and were told to go to their primary care physician or to go to another hospital. Interview revealed the staff offered to call 911 for the patients.

During an interview on 1/24/2024 at 10:54 AM, the Chief Executive Officer (CEO) confirmed the ED had been on diversion from 12:00 AM on 1/22/2024-1/24/2024 because there was no physician or midlevel provider to staff the ED and confirmed the ED was not receiving patients.

During an interview on 1/24/2024 at 12:45 PM, the ED Nurse Manager stated the CEO notified her on Sunday (1/21/2024) the ED would be going on diversion at midnight (1/22/2024) because there was no physician to staff the ED.

During a telephone interview on 1/24/2024 at 3:03 PM, the day shift RN #1 confirmed the ED was on diversion and was not accepting patients because there wasn't a physician or midlevel provider to staff the ED on 1/22/2024 and 1/23/2024. RN #1 confirmed patients had presented to the ED on those dates and were instructed to go to their primary care provider or the nearest ED.

During a telephone interview on 1/24/2024 at 3:21 PM, the night shift LPN #1 confirmed the ED was not staffed with a physician or midlevel provider after 12:00 AM on 1/22/2024 or on the night of 1/23/2024. LPN #1 confirmed patients who presented to the ED were told there was no physician for the ED and the staff could help them call 911 if needed.

During a telephone interview on 1/25/2024 at 8:07 AM, the CEO confirmed the ED continued to be without a provider and remained on diversion. The CEO stated ensuring nursing staff was in the ED and diverting patients to another ED was all he could do.

Based on review of Medical Staff Rules and Regulations, review of facility policy, review of a Health Alert Network (Public Health's notification system for rapidly disseminating alerts, updates and advisories to local, state, and federal partners) report, review of the Emergency Department (ED) physician schedule, review of the ED log (list of ED patients), review of an ED Diversion (redirected patients) log, observations and interviews, the facility failed to ensure availability of a physician or midlevel provider (physician assistant or nurse practitioner) in the ED 24 hours a day/7 days a week (24/7) affecting 16 patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) of 16 patients who presented to the ED from 1/22/2024-1/24/2024.

The findings include:

Review of the Medical Staff Rules and Regulations dated 3/2004 showed, "...Any individual who presents to the Emergency Department of the hospital for care shall be provided with a medical screening examination...All patients shall be examined by qualified medical personnel which shall be defined as a physician trained in emergency medicine..."

Review of the facility's policy "Scope of Services" revised 8/23/2021 showed, "...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel...Any patient presenting to the Emergency Department for care will be evaluated and treated..."

Review of a Health Alert Network report showed the facility went on diversion status on 1/21/2024 at 11:21 PM. The report showed the facility was on diversion due to no physician in the ED.

Review of the Emergency Department physician schedule for 1/2024 showed a physician nor midlevel provider was not scheduled from 12:00 AM on 1/22/2024-1/25/2024 at 7:00 PM.

Review of the ED log for 1/1/2024-1/24/2024 showed the last patient listed on the ED log arrived on 1/21/2024 at 10:00 PM and was discharged on 1/21/2024 at 11:45 PM. Patients listed on the ED Diversion Log were not listed on the ED Log.

Review of a facility handwritten document titled "Diversion Log" showed 16 patients listed by number (no patient names included) presented to the ED seeking treatment as follows:
*Patient #1 arrived on 1/21/2024 at 11:30 PM with complaint of (c/o)
neck pain.
*Patient #2 arrived on 1/22/2024 at 1:30 AM with c/o high fever.
*Patient #3 arrived on 1/22/2024 at 3:00 AM with c/o possible kidney
stone.
*Patient #4 arrived on 1/22/2024 at 9:04 AM with c/o panic attack.
*Patient #5 arrived on 1/22/2024 at 9:26 AM with c/o fall.
*Patient #6 arrived on 1/22/2024 at 11:56 AM with c/o head laceration
(wound).
*Patient #7 arrived on 1/22/2024 at 12:04 PM with c/o wrist pain.
*Patient #8 arrived on 1/22/2024 at 2:55 PM with c/o cough/not feeling
well.
*Patient #9 arrived on 1/22/2024 at 3:10 PM with c/o psychiatric
evaluation.
*Patient #10 arrived on 1/22/2024 at 3:55 PM with c/o fall.
*Patient #11 arrived on 1/22/2024 at 4:19 PM with c/o chest pain.
*Patient #12 arrived on 1/22/2024 at 9:23 PM with c/o intoxication.
*Patient #13 arrived on 1/23/2024 at 7:00 AM with c/o wrist pain.
*Patient #14 arrived on 1/23/2024 at 2:01 PM and asked for a
wheelchair.
*Patient #15 arrived on 1/23/2024 at 8:30 PM with c/o nausea and
vomiting.
*Patient #16 arrived on 1/23/2024 at 9:45 PM with c/o shortness of
breath and chest pain. Staff called 911 for the patient.

There were no medical records for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16.

Observation of the ED on 1/24/2024 at 10:09 AM showed a sign stating the ED was on diversion posted on the ED entrance from within the facility and the ED main entrance. The ED was staffed with 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN). No physician or midlevel provider was in the ED.

During an interview on 1/24/2024 at 10:54 AM, the Chief Executive Officer (CEO) confirmed the ED had been on diversion from 12:00 AM on 1/22/2024-1/24/2024 because there was no physician or midlevel provider (physician assistant or nurse practitioner) to staff the ED.

During an interview on 1/24/2024 at 12:45 PM, the ED Nurse Manager stated the CEO notified her on Sunday (1/21/2024) the ED would be going on diversion at midnight (1/22/2024) because there was no physician to staff the ED.

During a telephone interview on 1/24/2024 at 3:03 PM, RN #1 (day shift) confirmed the ED was on diversion and not accepting patients related to no physician or midlevel provider to staff the ED during her shifts on 1/22/2024 and 1/23/2024. RN #1 confirmed patients presented to the ED during those shifts and were instructed to go to their primary care provider or the nearest ED.

During a telephone interview on 1/24/2024 at 3:21 PM, LPN #1 confirmed the ED was not staffed with a physician or midlevel provider after 12:00 AM on 1/22/2024 or during the night of 1/23/2024. LPN #1 confirmed patients who presented to the ED were told there was no physician for the ED and the staff could help them call 911 if needed.

During a telephone interview on 1/25/2024 at 8:07 AM, the CEO confirmed the ED continued to be without a physician or midlevel provider and remained on diversion.

Based on review of Medical Staff Rules and Regulations, review of the Chief Executive Officer (CEO) job description, review of Advisory Board Bylaws, review of facility policy, review of Emergency Department (ED) physician schedule, review of ED log (list of ED patients), review of an ED Diversion (list of redirected patients) log, observations and interviews, the facility failed to provide oversight related to medical care for patients presenting to the ED.

The findings include:

The facility failed to ensure 24/7 (24 hours a day/7 days a week) availability of a physician or midlevel provider (physician assistant or nurse practitioner) in the ED to provide medical treatment for patients presenting to the ED. The facility was behind with payments to the contracted company who provided ED physicians, which resulted in the physicians not covering scheduled shifts in the ED and the ED being on diversion from 1/22/2024 at 12:00 AM-1/24/2024. Patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) presented to the ED but were turned away without receiving treatment.

Refer to C-0962.

Based on review of Medical Staff Rules and Regulations, review of the Chief Executive Officer (CEO) job description, review of Advisory Board Bylaws, review of facility policy, review of Emergency Department (ED) physician schedule, review of ED log (list of ED patients), review of an ED Diversion (list of redirected patients) log, observations and interviews, the facility failed to provide physician coverage in the ED from 1/22/2024-1/24/2024, affecting 16 patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) of 16 patients who presented to the ED from 1/22/2024-1/24/2024.

The findings include:

Review of the facility's Medical Staff Rules and Regulations dated 3/2004 showed, "...Any individual who presents to the Emergency Department of the hospital for care shall be provided with a medical screening examination...All patients shall be examined by qualified medical personnel which shall be defined as a physician trained in emergency medicine..."

Review of the Chief Executive Officer (CEO) job description dated 1/10/2017 showed, "...The Chief Executive Officer responsibility is to provide leadership, assume responsibility and accountability for the overall strategies planning of rural hospital including outpatient and inpatient services, diagnostic, emergency medical services, surgical services, and physician practice. Essential Duties and Responsibilities...Leads hospital leadership team and participates in medical staff and governance strategic planning sessions for hospital...Meets regularly with hospital leadership to examine current financial performance, evaluates forecasts and ensures appropriate, timely interventions...Assures consistent compliance with quality, risk, financial, and other expectations that are in accordance with expectations and directives...Plans and directs the short- and long-range objectives/goals of Corporate to meet its financial and non-financial goals..."

Review of the "Bylaws Governing the Advisory Board of [named facility]" dated 8/31/2018 showed, "...The role and purpose of the Hospital is to provide a facility supporting qualified medical professionals in providing quality health care to patients treated in the Hospital. The primary responsibility and goal of the Advisory Board (the "Board") is to further the role and purpose of the Hospital by providing oversight of the Hospital and advice to the Corporation and the Corporation's Board of Directors (the "Corporate Board"), thereby facilitating the establishment of policies, the maintenance of quality patient care, and the provision of institutional management and planning, all in a manner that is responsive to the needs of the community area...The Corporate Board serves as the governing body of the Hospital and retains ultimate responsibility for the Hospital's compliance with all applicable federal, state and local laws and regulations...The Corporate Board, through its officers and the CEO, retains authority for the Hospital's business decisions, but may request the advice of the Board on such matters...The Board shall advise the Corporation...making recommendations to the CEO and the Corporation regarding the Hospital's operating budget, which shall be developed by the CEO..."

Review of the facility's policy "Scope of Services" revised 8/23/2021 showed, "...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel...Any patient presenting to the Emergency Department for care will be evaluated and treated... All services provided by [named facility] will be evaluated on an ongoing basis to ensure the needs of the patients and community are being met to the highest capabilities of the facility..."

Review of the ED physician schedule for 1/2024 showed a physician was not scheduled from 12:00 AM on 1/22/2024-1/25/2024 at 7:00 PM.

Review of the ED log for 1/1/2024-1/24/2024 showed the last patient listed on the ED log arrived on 1/21/2024 at 10:00 PM and was discharged on 1/21/2024 at 11:45 PM.

Review of a facility handwritten document titled "Diversion Log" showed 16 patients listed by number (no patient names included) presented to the ED seeking treatment as follows:
*Patient #1 arrived on 1/21/2024 at 11:30 PM with complaint of (c/o)
neck pain.
*Patient #2 arrived on 1/22/2024 at 1:30 AM with c/o high fever.
*Patient #3 arrived on 1/22/2024 at 3:00 AM with c/o possible kidney
stone.
*Patient #4 arrived on 1/22/2024 at 9:04 AM with c/o panic attack.
*Patient #5 arrived on 1/22/2024 at 9:26 AM with c/o fall.
*Patient #6 arrived on 1/22/2024 at 11:56 AM with c/o head laceration
(wound).
*Patient #7 arrived on 1/22/2024 at 12:04 PM with c/o wrist pain.
*Patient #8 arrived on 1/22/2024 at 2:55 PM with c/o cough/not feeling
well.
*Patient #9 arrived on 1/22/2024 at 3:10 PM with c/o psychiatric
evaluation.
*Patient #10 arrived on 1/22/2024 at 3:55 PM with c/o fall.
*Patient #11 arrived on 1/22/2024 at 4:19 PM with c/o chest pain.
*Patient #12 arrived on 1/22/2024 at 9:23 PM with c/o intoxication.
*Patient #13 arrived on 1/23/2024 at 7:00 AM with c/o wrist pain.
*Patient #14 arrived on 1/23/2024 at 2:01 PM and asked for a
wheelchair.
*Patient #15 arrived on 1/23/2024 at 8:30 PM with c/o nausea and
vomiting.
*Patient #16 arrived on 1/23/2024 at 9:45 PM with c/o shortness of
breath and chest pain. Staff called 911 for the patient.

Observation of the facility's main entrance door on 1/24/2024 at 9:45 AM showed a sign was posted stating the ED was on diversion.

Observation of the ED on 1/24/2024 at 10:09 AM showed a sign stating the ED was on diversion was posted on the ED entrance from within the facility and the ED main entrance. The ED was staffed with 1 Registered Nurse and 1 Licensed Practical Nurse. No physician or midlevel provider was in the ED.

During an interview on 1/24/2024 at 10:54 AM, the CEO stated the company contracted to provide ED physicians/midlevel providers informed him a specific provider, who had not received payment for his services for the end of 12/2023, as well as other ED providers would not provide services for the ED unless they were paid in advance. The CEO reported the facility was 1 month behind in payment to the contracted company. The CEO confirmed the ED had been on diversion since 12:00 AM on 1/22/2024 because there was no physician or midlevel provider to staff the ED. The CEO confirmed the ED remained on diversion on 1/24/2024.

During an interview on 1/24/2024 at 12:45 PM, the ED Nurse Manager stated the CEO notified her on Sunday (1/21/2024) the ED would be going on diversion at midnight (1/22/2024) because there was no physician to staff the ED.

During a telephone interview on 1/24/2024 at 3:25 PM, the ED Medical Director, stated the expectation was the facility make "on time" payments for services provided by the ED physicians. He stated the facility had occasionally gotten behind but had been able to make it up. The ED Medical Director reported the facility started getting behind with payment around 9/2023 or 10/2023. According to the ED Medical Director, the facility had not paid the contracted company who provided ED physicians (ED Medical Director's employer) for services provided in 11/2023, 12/2023 and 1/2024. The Medical Director stated, "...[named contracted company] is saying not paying money until [facility corporate office] pays them...the docs [doctors] aren't getting paid...They owe me for December [2023] and January [2024]...no doctor coverage because they aren't paying the doctors..." The Medical Director stated the contracted company is not guaranteeing payment if the ED physicians work their scheduled shifts, "...None of the doctors are wanting to return to work until they are paid. The truth of the matter is they [the facility] are behind on payments..."

During a telephone interview on 1/25/2024 at 2:48 PM, the CEO stated the contracted company who provided the physicians for the ED had been paid for services through mid-December. The CEO stated he collaborated with the corporate office to handle the facility's cash flow. When asked who was responsible for ensuring accounts were paid, the CEO responded, "...would have to be me locally..." He went on to say the contracted company was paid through the corporate office.

During a telephone interview on 1/26/2024 at 12:45 PM, the Community Advisory Board Chairperson stated the facility CEO shared information regarding hospital operations, environment of care report, administrative report, brief recap from medical staff meeting, quality improvement, human resources and nursing. The Advisory Board Chairperson understood there was an issue with the contracted company who provided ED physicians and the physicians "...bucked..." on providing services for the ED. She was not aware of the facility making late payments to the contracted company. The Community Advisory Board Chairperson stated, "...I was told they were paid up through mid-December. I assume by being paid up through mid-December they are up to date..."

During a telephone interview on 1/26/2024 at 1:05 PM, the Corporate CEO stated it was his responsibility to "...Watch and manage cash flow...financial management..." The Corporate CEO stated the facility had paid the contracted company who provided ED physicians through 12/15/2023 or 12/20/2023 for the second part of December and stated "...We have paid them as cash flow has come in..." The Corporate CEO stated the contracted provider group had been paid consistently until 5/2023. He stated, "...probably slipped a little in July [2023]...consistently been behind [with payment] 4-6 weeks...since that time." The Corporate CEO stated some of the ED providers insisted on being paid in advance, but the facility was unable to meet their request which resulted in the ED going on diversion.