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Based on interview, record review, and review of facility policies and bylaws, it was determined the facility failed to have an effective governing body that was responsible for the conduct of the facility, and failed to ensure the facility had the financial means to operate effectively and protect the health and safety of patients. Observations and interviews conducted throughout the facility on 01/22-24/19 and 01/28-30/19 revealed the Chief Executive Officer (CEO) was aware the facility did not have adequate supplies and medications, but failed to provide oversight to ensure quality care was being provided.

In addition, the facility failed to have an overall institutional plan that included an annual operating budget that included all anticipated income, expenses, and/or capital expenditures for a three-year period. Observations and interviews with staff revealed the facility failed to have adequate supplies, equipment, or medications to adequately care for patients due to budgetary constraints and the facility's inability to obtain cash flow to purchase needed items. The facility also had a debt with the Pharmacy Distributor of approximately one-half million dollars, and with their electronic medical records vendor of approximately six hundred thousand dollars, and all vendors supplying the facility were now refusing to provide services and goods without upfront payments.

Interviews with the facility's Chief Nursing Officer (CNO), Chief Financial Officer (CFO), and Chief Executive Officer (CEO) revealed the facility had no plan to ensure the facility could continue to operate.

(Refer to A0057, A0073, A0115, A0145, A0263, A0273, A0385, A0395, A0489, A0490, A0799, A0837, A0940, A0951, A0955, A1100, A1103, and A1104.)

Based on observation, interview, record review, review of the facility's Abuse/Neglect policy, and review of medical records from Facilities #2, #3, and #4, it was determined the facility failed to protect the rights of six (6) of twelve (12) patients. Observations revealed the facility provided Emergency Department (ED) services, and Surgical Services (services were limited to general surgery), and had a twelve (12) bed medical surgical inpatient unit. Interviews revealed the facility did not provide intensive/critical care services and had no policy/procedure in place regarding the scope of services that the medical surgical unit could provide. Subsequently, the facility admitted Patients #2, #8, and #11 for treatment of diagnoses that the facility could not provide. Patient #2 was admitted with chest pain and to rule out a heart attack even though the facility did not have cardiology services available or an intensive care unit to monitor the patient. The facility failed to conduct heart testing, blood pressure monitoring, and laboratory testing to monitor the patient's cardiac status as ordered by the patient's physician. When the patient developed a heart arrhythmia, the facility failed to notify the patient's physician timely, and Patient #2 was not transferred to an acute care facility for cardiac assessment and treatment until approximately 34 (thirty-four) hours after the patient presented to the ED and developed chest pain.

Patient #8 was directly admitted to the medical surgical unit with signs and symptoms of a stroke, even though the facility did not have a neurologist or speech/occupational/physical therapy services. The facility failed to administer medications to the patient for treatment of high blood pressure/chest pain, and chronic kidney disease. Interviews revealed staff notified the patient's physician that the patient was having stroke symptoms; however, the physician failed to transfer the patient to another facility for neurological assessment and care until the day after admission. According to the nurse, the physician stated, "Don't call me back anymore. We'll sit on it tonight and transfer [him/her] out tomorrow."

The facility admitted Patient #11 to Surgical Services on 09/21/18 for treatment of Gall Stones with pain, nausea, vomiting, etc., even though the ED physician was "uncertain if anesthesia was available." The consulting Gastrointestinal Physician saw Patient #11 on 09/21/18, and his recommendations were to transfer the patient "where they can do surgery." However, the facility failed to transfer Patient #11 for treatment until 09/24/18, three days later.

In addition, Patient #5 presented to the facility's Emergency Department (ED) on 11/26/18 with hip pain. The facility failed to obtain a hip x-ray until after the patient was admitted on 11/27/18. The x-ray revealed the patient's hip was fractured; however, the facility did not transfer the patient to obtain treatment for the fracture until 11/28/18. In addition, the patient had physician orders for a regular diet; however, the patient had a feeding tube due to swallowing issues and could not consume a diet by mouth. The facility failed to contact the physician or the Registered Dietitian to ensure the patient received appropriate nourishment and the patient received no tube feeding while at the facility for approximately two days. Further, the facility failed to assess and treat wounds to the patient's leg and cigarette burns to the patient's fingers and failed to administer medications to the patient as ordered by the physician.

Patient #3 presented to the facility ED on 12/30/18 at 2:35 PM with severe left foot pain and the patient's left foot and little toe were blue in color and cold. At 3:30 PM, the ED physician ordered Lovenox (used to prevent and treat blood clots), Zosyn (antibiotic), and Demerol (medication to treat pain); however, staff failed to administer Lovenox and Zosyn until the next day, approximately twenty-four hours after the medication was ordered. In addition, at 4:13 PM, testing confirmed the patient had a blood clot in an artery in the leg that was blocking blood flow. However, the facility admitted the patient to the facility and did not transfer Patient #3 to a facility that could treat the blood clot until 01/01/19 at 12:00 PM.

The facility admitted Patient #4 for treatment of Congestive Heart Failure and Diabetes but failed to administer the patient's Insulin because it was not available at the facility. Then, when the patient's blood sugar was high, the facility failed to notify the patient's physician as ordered of the elevated blood sugars.

Based on observation, interview, record review, and review of the facility's Quality Management Manual and Performance Indicators, it was determined the facility failed to implement and maintain an effective ongoing, hospital-wide, data-driven Quality Assurance and Performance Improvement (QAPI) Program. Interviews with the Chief Nursing Officer and Assistant Chief Nursing Officer revealed the facility had not conducted QAPI activity since the Director of QAPI resigned in July 2018. Review of QAPI Minutes revealed the last meeting was in October 2018 and review of Performance Indicators revealed the facility failed to conduct QAPI activities during the last quarter of 2018. Subsequently, review of patient records and interviews with staff revealed the facility failed to identify patient care and patient safety concerns and failed to develop action plans to address the concerns.

(Refer to A0043, A0057, A0073, A0115, A0145, A0273, A0385, A0395, A0489, A0490, A0799, A0837, A0940, A0951, A0955, A1100, A1103, and A1104.)

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure nursing services were provided or supervised by a registered nurse. The facility failed to have a system for consulting the Registered Dietitian (RD) when patients had feeding tubes, pressure ulcers/wounds, or Diabetes and failed to have an effective system to ensure patients received physician ordered diets. The RD stated he had only consulted on one patient in the approximately eight months that he had been contracted with the facility. According to the Dietary Manager, staff did not consult the RD "because he charges $140.00 an hour and with the budget we have to operate on, we can't afford him." The facility failed to consult the RD for Patient #7 who had a diagnosis of cellulitis and a Stage 2 pressure sore or for Patient #4 who had a diagnosis of Diabetes and was not receiving/eating the ordered diet. In addition, the facility failed to ensure Patients #4 and #7 received diets as ordered by their physicians.

Further, the facility did not have an effective system for ensuring Social Services was consulted. A consultation was recommended for Patient #7 who had no running water at home and did not have access to care and medications; however, a social services consultation was never completed and Patient #7 was discharged home.

In addition, the facility failed to administer medications to Patients #4 and #7 as ordered by their physicians. Patient #7's medical record revealed the patient was admitted on 01/06/19 with Cellulitis to the right lower extremity (skin infection), early sepsis (a potentially life-threatening condition caused by the body's response to an infection), and a Stage 2 pressure sore. The facility failed to administer Lovenox medication to prevent blood clots for patients as ordered by the physician and failed to ensure the pressure sore was assessed/treated.

The facility also failed to ensure Patient #4's diuretic medication and potassium supplement were administered as ordered by the patient's physician, and failed to monitor and notify the patient's physician of the patient's urinary output.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure pharmaceutical services were provided to meet the needs of patients. Interviews and review of emails revealed that effective 01/24/19, the facility did not have a Pharmacy Distributor to supply medications to the facility. According to the email, the retail pharmacy was "turning over the handling of outstanding amounts to our legal team and will no longer be able to service the account." Observation, interview, and record review revealed the facility failed to have medications that were required by the facility's formulary; including antibiotics, intravenous fluids, and medications required for emergencies including Verapamil (used to treat high blood pressure, chest pain, and heart arrhythmia), Epinephrine (used to treat life threatening allergic reactions and cardiac arrest), and Sodium Bicarbonate (used in emergencies for cardiac arrest and metabolic acidosis). In addition, the facility only had one (1) dose of Activase (used to treat blood clots in patients having heart attacks and strokes). Interviews revealed the facility was unsure how they were going to obtain medications for use at the facility.

Based on interview, record review, and review of facility policy, it was determined that the facility failed to have an effective discharge planning process for one (1) of twelve (12) patients (Patient #9). On 01/16/19 at 5:30 PM, a social services consultation was requested for Patient #9 because the patient did not have running water at home and did not have transportation to/from appointments or the pharmacy. However, the facility failed to conduct a social services consultation and discharged Patient #9 home on 01/23/19.

Based on interviews, record reviews, review of a facility policy, and review of a facility investigation, it was determined the facility failed to ensure well-organized surgical services were provided in accordance with acceptable standards of practice.

Observations and interviews with staff revealed the facility failed to maintain surgical equipment in working order, failed to have formulary medications available for sedation and emergencies, and failed to ensure cleaner/disinfectant used to clean/sanitize surgical instruments and operating rooms was not expired.

In addition, on 08/16/18, Patient #1 was admitted for abdominal pain and signed a consent to have an Esophagogastroduodenoscopy (EGD) (a procedure to examine the stomach and upper portion of the small intestine). However, review of the "Operating Room Nurses Note" and a facility investigation revealed the facility attempted to perform a colonoscopy (a procedure to examine the colon from the rectum) and performed a sigmoidoscopy (examined the inner part of the rectum and lower colon) without the patient's consent.

Based on observation, interview, record review, review of facility policies/procedures, and review of the American Heart Association/American Stroke Association Guidelines, it was determined the facility failed to meet the emergency needs of patients in accordance with acceptable standards of practice. The facility failed to ensure the Emergency Department was integrated with other departments of the facility to ensure the facility could immediately make available the full extent of its patient care resources to assess and render appropriate care for emergency patients, and failed to ensure the policies and procedures governing medical care provided in the Emergency Department were a continuing responsibility of the medical staff.

Patient #12 presented to the Emergency Department (ED) on 12/04/18, in full cardiac arrest. On two different occasions, Patient #12 required multiple doses of Epinephrine (a medication to stimulate the heart) in an effort to sustain the patient's life. However, the facility failed to have enough medication to treat the patient, and medication had to be supplied to the facility by the Emergency Medical Services (EMS) that had transported the patient to the ED. Observation of the facility's ED on 01/30/19 at 5:00 PM revealed four (4) ampules of Epinephrine were available for an adult patient and four (4) ampules of Epinephrine for a pediatric patient. However, all eight ampules of Epinephrine had expiration dates of 01/31/19, the next day, and the facility had no available Epinephrine to replace the medication and could not purchase any medication because their retail vendor stopped releasing medication to the facility due to unpaid debt.

On 07/17/18, EMS was attempting to transfer a patient to the ED who was exhibiting signs and symptoms of an acute stroke. However, when EMS contacted the ED to inform them that they were en route with the patient, they were informed by RN #11 not to bring the patient to the ED because they would "kill this guy." Subsequently, EMS contacted a transport helicopter and the patient was flown to another facility.

Further, the facility had an "Acute Stroke Practice Standard for the Emergency Department" in place with specific criteria and interventions for the medical staff to follow and implement when a patient presented to the Emergency Department (ED) with signs/symptoms of a stroke. However, the facility failed to implement the standard of care on 11/12/18 at 10:35 AM, when Patient #10 presented to the ED with a "significantly elevated blood pressure" and exhibiting signs and symptoms of a stroke. The facility failed to implement their Acute Stroke Practice Standard for the Emergency Department; subsequently, Patient #10 did not receive medical imaging including a non-contrast head computed tomography (CT) scan until after being admitted to the medical surgical floor and five (5) hours after arrival to the ED. In addition, the facility failed to administer Patient #10 the stroke scale assessment screening to determine the extent of deficits being experienced by the patient. On 11/12/18 at 4:20 PM, the results of a CT scan of the head for Patient #10 revealed the patient was experiencing an apparent evolving stroke. The patient was transferred to Facility #6 on 11/12/18 at 8:15 PM for treatment of an acute stroke.

The facility failed to have more than one Tissue Plasminogen Activator (tPA) (a medication administered to dissolve blood clots, name brand Activase), used to treat patients who were having a stroke. Interviews revealed the facility had been unable to purchase the medication in the past because the medication cost $10,000. However, as of 01/24/19, the facility did not have a retail pharmacy vendor from which to purchase any medication.

Tours of the Emergency Department (ED) on 01/23/19 and 01/30/19 revealed the facility did not have a functioning telemetry monitor (shows the electrical activity of the heart) located at the nursing station, and staff were unable to monitor a patient's cardiac status unless they were present in the patient's room. Further observations revealed eight (8) of nine (9) rooms in the ED did not have a functional pulse oximeter (a device used to measures the amount of oxygen in the blood). Observations in the ED also revealed none of the nine (9) ED rooms contained a functional biohazard "sharps" container. There were only two (2) biohazard "sharps" containers located in the ED; one container was located in the hallway and another in the physician's charting room. Observations on 01/30/19 revealed ED staff had to transport used needles and devices through the hallway to get to a biohazard container to dispose of the items. In addition, observation of the casting room on 01/23/19 at 9:45 AM revealed it contained a limited number of supplies necessary to cast fractured bones of patients presenting to the ED in need of casting services. The ED's entire supply of casting tape was expired and the appropriate sizes were not available to treat various injuries.

Based on interview, record review, and review of facility policies and bylaws, it was determined the facility failed to have an effective governing body that was responsible for the conduct of the facility, and failed to ensure the facility had the financial means to operate effectively and protect the health and safety of patients. Observations and interviews conducted throughout the facility on 01/22-24/19 and 01/28-30/19 revealed the Chief Executive Officer (CEO) was aware the facility did not have adequate supplies and medications, and therefore was failing to provide goods and services necessary to care for patients.

The findings include:

Review of the facility policy titled "Governing Board Responsibilities," approved June 2017, revealed the governing board would meet at least twice annually and was responsible for the conduct of the facility consistent with the objectives of the facility and consistent with established standards of patient care.

Review of Patient #1's medical record revealed the patient was admitted to the facility for abdominal pain on 08/16/18 and signed a consent on 08/16/18 to have an esophagogastroduodenoscopy (EGD); however, on 08/16/18 the facility performed a colonoscopy on the patient by mistake.

Review of Patient #2's medical record revealed the facility admitted the patient on 10/10/18 with chest pain and to rule out a heart attack even though the facility did not have cardiology services available or an intensive care unit to monitor the patient. Further review of Patient #2's record revealed the facility failed to conduct heart testing, blood pressure monitoring, and laboratory testing to monitor the patient's cardiac status as ordered by the patient's physician. On 10/11/18 at 10:14 AM the patient developed a heart arrhythmia, but the facility failed to notify the patient's physician timely and Patient #2 was not transferred to an acute care facility for cardiac assessment and treatment until 10/11/18 at 6:00 PM, approximately thirty-four hours after the patient presented to the ED.

Review of Patient #3's medical record revealed the patient presented to the facility's ED on 12/30/18 with severe left foot pain and review of the ED record revealed the patient's left foot and little toe were blue in color and cold. At 3:30 PM, the ED physician ordered Lovenox (used to prevent and treat blood clots) and Zosyn (antibiotic) to be administered to the patient; however, staff failed to administer Lovenox and Zosyn until 12/31/18, approximately twenty-four hours after the medication was ordered.

Review of Patient #4's medical record revealed the patient was admitted for treatment of Congestive Heart Failure and Diabetes on 01/22/19. However, the facility failed to administer the patient's Insulin on 01/22/19 because it was not available. Further review of the medical record revealed the physician ordered on 01/23/19 to be notified when the patient's blood glucose was above 200. However the record revealed on 01/23/19 and 01/24/19, the physician was not notified when the patient's blood sugar was elevated above 200.

Review of Patient #5's medical record revealed the patient presented to the ED with hip pain on 11/26/18; however, a hip X-ray was not obtained until 11/27/18. The x-ray revealed the patient's hip was fractured. However, the facility did not transfer the patient to obtain treatment for the fracture until 11/28/18. The facility also failed to provide tube feeding to Patient #5 while admitted to the facility from 11/26/18 through 11/28/18. In addition, the facility also failed to assess and treat wounds to the patient's leg and cigarette burns to the patient's fingers while being admitted to the facility from 11/26/18 through 11/28/18, and failed to administer the patient four (4) STAT medications on 11/26/18 until (two) 2 hours after the medications were ordered by the physician.

Medical record review revealed the facility admitted Patient #7 to the facility on 01/06/19 with Cellulitis to the right lower extremity (skin infection), early sepsis (a potentially life-threatening condition caused by the body's response to an infection), and a Stage 2 pressure sore. However, the facility failed to administer the patient's Lovenox (medication to prevent blood clots) on 01/06/19 and it was not administered to the patient until 01/07/19, approximately twenty-two (22) hours after it was ordered by the physician and failed to ensure the patient's pressure sore was assessed/treated.

Review of Patient #8's medical record revealed the patient was directly admitted to the medical surgical unit on 01/21/19 with signs and symptoms of stroke, even though the facility did not have a neurologist or speech/occupational/physical therapy services. In addition, the physician failed to transfer the patient to another facility for neurological assessment and care until 01/22/19 the day after admission.

Review of Patient #10's medical record revealed Patient #10 presented to the ED on 11/12/18 with a "significantly elevated blood pressure" and exhibited signs and symptoms of a stroke. However, the patient did not receive medical imaging including a non-contrast head computed tomography (CT) scan until after being admitted to the medical/surgical floor and five (5) hours after arrival to the ED. Patient #10 was transferred to Facility #6 on 11/12/18 at 8:15 PM for treatment of an acute stroke.

Review of Patient #11's medical record revealed the patient was admitted to surgical services on 09/21/18 at 9:40 PM for treatment of Gall Stones with pain, nausea, vomiting, etc., even though the ED physician was "uncertain if anesthesia was available." The consulting Gastrointestinal Physician saw Patient #11 on 09/21/18 and his recommendations were to transfer the patient "where they can do surgery." However, the facility failed to transfer Patient #11 for treatment until 09/24/18, three days later.

Review of Patient #12's medical record revealed Patient #12 presented to the Emergency Department (ED) in full cardiac arrest on 12/04/18. On two different occasions the patient required multiple doses of Epinephrine (a medication to stimulate the heart) in an effort to sustain the patient's life. However, the facility failed to have enough Epinepherine to treat the patient, and Epinepherine had to be supplied to the facility by the Emergency Medical Services (EMS) that had transported the patient to the ED.

Interview with the Emergency Medical Director on 01/29/19 at 2:45 PM, revealed on 07/17/18, EMS was attempting to transfer an unknown patient to the ED who was exhibiting signs and symptoms of an acute stroke. However, when EMS contacted the ED to inform them that they were en route with the patient, they were informed by RN #11 not to bring the patient to the ED because they would "kill this guy." Subsequently, EMS contacted a transport helicopter and the patient was flown to another facility.

The facility failed to have a system for consulting the Registered Dietitian (RD) when patients had feeding tubes, pressure ulcers/wounds, or Diabetes, and failed to have an effective system to ensure patients received physician ordered diets.

Tour of the Emergency Department (ED) on 01/23/19 9:45 AM and 1/30/19 at 5:15 PM revealed the facility did not have a functioning telemetry monitor (shows the electrical activity of the heart) located at the nursing station, and staff were unable to monitor a patient's cardiac status unless they were present in the patient's room. Further observations revealed eight (8) of nine (9) rooms in the ED did not have a functional pulse oximeter (a device used to measures the amount of oxygen in the blood). Observations in the ED also revealed none of the nine (9) ED rooms contained a functional biohazard "sharps" container. Observations on 1/30/19 at 5:15 PM revealed ED staff had to transport used needles and devices through the hallway to get to a biohazard container to dispose of the items. In addition, observation of the casting room revealed it contained a limited number of supplies necessary to cast fractured bones of patients presenting to the ED in need of casting services. The ED's entire supply of casting tape was expired and the appropriate sizes were not available to treat various injuries.

Observations of the Surgical Department on 01/23/ at 10:50 AM revealed the department's surgical disinfectant solutions that they were currently utilizing to clean and disinfect the surgical rooms and surgical instruments (VirexTB and Envy ) had expired in 2018. Interviews on 01/23/19 at 10:55 AM with Sterile Processing Technician #1 and at 11:00 AM with Sterile processing Technician #2 revealed during a period in December 2018 (exact date unknown) no instruments could be sterilized due to no biologics being available. Interview with Physician #9 on 01/30/19 at 11:00 AM revealed he stopped practicing at the facility in October 2018 because continuing to provide care in the facility was endangering the lives of his patients. The physician stated there was not adequate equipment or supplies in the surgery department, there had been times when instruments could not be sterilized, and staff has had to leave in the middle of a surgical procedure to search the facility for needed supplies.

Interview with the Director of Pharmacy on 01/23/19 at 2:45 PM revealed the facility had only one (1) Activase (used to treat blood clots in patients having heart attacks and strokes) in the entire building and she had informed the facility's physicians of this situation. The Director of Pharmacy stated the reason for the lack of medications was the cost. The Director of Pharmacy stated the facility owed around half a million dollars to the drug distributor for the facility and could not order any more medications without paying up front. Continued interview revealed that there are some medications in the pharmacy that have expired that the facility cannot replace them due to the cost. Continued interview with the Director of Pharmacy revealed she had emailed the CEO and the medication distribution vendor and the vendor referred her to their legal department. The Director of Pharmacy stated she was filling the crash carts with the last of the Vasopressin, Verapamil, EPI, Nitroglycerin 50/250ml, and Sodium Bicarbonate 8.4%50 ml and she would have no ability to obtain anymore. The Director of Pharmacy stated to sign up with another medication distribution vendor would take eight (8) weeks or more and the CEO's plan was to "borrow" medication from a facility that he was attempting to purchase on 02/01/19 in Missouri. The Director of Pharmacy was questioning the surveyors regarding the legalities of this "scheme."

Review of the last Governing Board Meeting Minutes conducted by the facility dated 08/21/18, revealed the meeting was a virtual meeting and three (3) members were present. The Governing Body made recommendations to approve temporary privileges for eight (8) physicians, approved the privileges of the former administration's medical staff for six (6) months, and adopted the former administration's bylaws, rules/regulations, and policies/procedures. Further review of the meeting minutes revealed no other discussions took place or no further actions taken.

Interview with a Former Governing Body Member on 01/30/19 at 2:07 PM, revealed that she was no longer employed by the facility's corporation and no longer functioned as a governing body member as of "last week." The Former Member stated that the Chief Executive Officer (CEO) was responsible for "ninety percent" of oversight provided to the facility, and had daily communication with the Chief Nursing Officer (CNO) and the Chief Financial Officer (CFO) who are at the facility. The Former Member stated that the Governing Body only met "sporadically and not consistently." The Former Member was unable to state when the last governing body meeting was held for the facility or what members besides herself had made up the governing body. The Former Member stated that there was constant conversation about the facility's finances, and that the cash flow of the facility was always the topic of priority. The Former Member stated that she was not aware of a meeting or conversation she had attended or participated in regarding the facility that was not dominated by finances. The Former Member stated she was never involved in or aware of care concerns at the facility.

Interview on 01/30/19 at 2:38 PM with the CEO and Owner of the facility revealed the CNO and CFO function as the onsite administration at the facility, and are responsible for the day to day operations. The CEO stated he provided oversight by talking via telephone to the CNO and CFO several times a day. The CEO stated that he and two other members comprise the governing body of the facility, but was unable to state who the other two members were. The CEO was unable to state how often the governing body met or provide any structural details of the meetings. The CEO was unable to say what was routinely discussed in the governing body meetings or when the last meeting had occurred. The CEO stated the governing body had never been informed or discussed any adverse events that had occurred at the facility.

(Refer to A0043, A0073, A0115, A0145, A0263, A0273, A0385, A0395, A0489, A0490, A0799, A0837, A0940, A0951, A0955, A1100, A1103, and A1104.)

Based on record review and interview it was determined the facility failed to have an overall institutional plan with an annual operating budget that included all anticipated income and expenses, and contained capital expenditures for a three-year period. Observations and interviews with staff revealed the facility failed to have adequate supplies, equipment, or medications to adequately care for patients due to budgetary constraints and the facility's inability to obtain cash flow to purchase needed items. The facility owes their supplying pharmacy approximately one-half million dollars, and their electronic medical records vendor approximately six hundred thousand dollars, and all vendors supplying the facility are now refusing to provide services and goods without prepayment payments.

Interviews with the facility's Chief Nursing Officer (CNO), Chief Financial Officer (CFO), and Chief Executive Officer (CEO) revealed the facility had no plan to ensure the facility could continue to operate.

The findings include:

Interview with the facility's CFO on 01/28/19 at 6:00 PM, revealed the facility did not have a policy or procedure related to the development of a budget.

Review of the facility's "Operating Budget for the Period Ending June 30, 2019" revealed the facility had projected total net revenue of 927,110 dollars for each month from July 2018 through December 2018. Further review revealed the facility had projected total operating expenses of 1,175,517 dollars for each month from July 2018 through December 2018. Therefore, the facility had a projected net operating loss of 248,407 dollars for each month from July 2018 through December 2018.

Further review of the Operating Budget revealed for January 2019 the facility had a projected net revenue of 1,012,460 dollars and projected total operating expenses of 1,087,033 dollars. For February 2019, the facility had a projected net revenue of 1,046,577 dollars, and projected total operating expenses of 1,019,404 dollars. For March 2019, the facility had a projected net revenue of 1,082,401 dollars and projected total operating expenses of 958,539 dollars. For April 2019, the facility had a projected net revenue of 1,120,016 dollars, and projected total operating expenses of 903,760 dollars. Continued review for May 2019 revealed the facility had a projected net revenue of 1,159,512 dollars and projected total operating expenses of 903,760 dollars, and for June 2019 the facility had a projected net revenue of 1,200,982 dollars and projected of total operating expenses of 903,760 dollars.

Continued review of the facility's Operating Budget revealed for the fiscal year of July 2018 through June 2019, the facility projected a loss of 644,748 dollars.

The facility was unable to provide a three-year plan for capital expenditures.

Observations made throughout the facility on 01/22-24/19 and 01/28-30/19 revealed the facility was operating with a Medical/Surgical Floor, Emergency Department, and Surgical Department. Continued observations revealed the facility had a lack of necessary supplies in all areas to ensure patients received adequate care and services.

Observations and interviews from 01/22-24/19 and 01/28-30/19 revealed on the medical surgical unit, staff were limited to how much linen they could utilize for patients due to linen delivery being cut back to once per month; patients did not have ordered medications because they were not available from the pharmacy. Interview with Physician #5 on 01/29/19 at 4:30 PM revealed he was instructing patients to bring medications from home to be administered to them while they were admitted to the facility.

Observations in the Emergency Department on 01/23/19 at 9:45 AM and 01/30/19 at 5:15 PM, revealed the facility did not have a functioning telemetry monitor (shows the electrical activity of the heart) located at the nursing station, and staff were unable to monitor a patient's cardiac status unless they were present in the patient's room; eight (8) of nine (9) rooms in the ED did not have a functional pulse oximeter (a device used to measures the amount of oxygen in the blood); none of the nine (9) ED rooms contained a functional biohazard "sharps" container; and the ED's entire supply of casting tape was expired and the appropriate sizes were not available to treat various injuries.

Observations of the Surgical Department on 01/23/19 at 10:50 AM revealed the department's supply of surgical disinfectant solutions (Virex TB and Envy)that the staff was currently utilizing to clean and disinfect the surgical rooms and surgical instruments had expired in 2018. Interviews on 01/23/19 at 10:55 AM with Sterile Processing Technician #1 and at 11:00 AM with Sterile Processing Technician #2 revealed during a period in December 2018 (exact unknown) no instruments could be sterilized due to no biologics being available. Interview with Physician #9 01/30/19 at 11:00 AM revealed he stopped practicing at the facility in October 2018, because continuing to provide care in the facility was endangering the lives of his patients. The physician stated there was not adequate equipment or supplies in the Surgery Department, there had been times when instruments could not be sterilized, and staff has had to leave in the middle of a surgical procedure to search the facility for needed supplies.

Interviews on 01/22/19, with the CNO at 12:00 PM, and the ACNO at 12:30 PM, revealed they were aware that the facility had an overall lack of supplies and was unable to obtain medications for administration to patients due to a lack of funds to pay for the services. The CNO and ACNO stated any vendor currently contracted with the facility would not provide services unless payment was received in advance, and with no funds available, services could not be paid for. The CNO stated she talked daily with the CFO and did not know of any solutions to the facility's current financial problems. The CNO stated her primary goal on a day to day basis was to ensure patients received adequate care in the facility. However, the CNO stated that was becoming more and more difficult to do each day. In addition, the CNO and ACNO stated the facility had been unable to meet payroll for facility staff consistently since the current CEO had taken over the facility in May of 2018. In addition the CNO stated that employees had been having health insurance premiums deducted from their paychecks by the facility; however, the facility had not been paying the insurance premiums and the staff was without coverage. The administrators went on to say that direct care staff planned to "walk out" of the facility the next time they did not receive a paycheck timely.

Interview with the facility's CFO on 01/28/19 at 6:00 PM revealed he was responsible for the day to finances at the facility, and had been since the current CEO had acquired the facility in May of 2018. He stated he was in contact with the Chief Executive Officer (CEO) daily. The CFO stated the numbers utilized for the Operating Budget came from the CEO, and the CFO was unable to explain why the facility's total net revenue and net operating income had remained exactly the same for July 2018 through December 2018. In addition, the CFO was unable to explain why the facility did not have a three-year budget plan as required. The CFO stated that his main priority at the facility was to manage day to day expenses and attempt to obtain the most critical services and inventory needed to fund the facility and keep it running. The CFO stated that the facility had no viable plan to make up the facility losses nor plans on paying overdue expenditures, such as the facility's pharmacy supplier who was owed approximately "one-half million dollars" or the approximately "six hundred thousand dollars" the facility owed the medical records vendor. Continued interview with the CFO revealed the physical building comprising the facility was currently being "litigated in Federal Bankruptcy Court, and the CEO was attempting to purchase the building." However, "there was opposition to the acquisition"; therefore, "there was no way to gain capital from the physical building such as through a loan or mortgage."

Interview with a Former Governing Body Member on 01/30/19 at 2:07 PM, revealed she was no longer employed by the facility's corporation and no longer functioned as a governing body member as of "last week." The Former Member stated the Chief Executive Officer (CEO) and the Chief Financial Officer (CFO) spoke daily related to the facility's finances. The Former Member stated the facility has significant financial constraints. The Former Member stated that the most urgent problem at the facility as of last week was "cash flow coming through the door." The Former Member stated that she was unsure of the facility's specific budget plans but knew that the facility was expecting the 2018 cost report to return a high settlement back to the hospital. The Former Member stated that she unaware if the facility had developed a "formalized" budget since the acquisition of the facility had occurred approximately six (6) months ago.

Interview on 01/30/19 at 2:38 PM with the Chief Executive Officer (CEO) and Owner of the facility revealed the facility was in a "turnaround mode" and he was constantly looking for ways to "turn the hospital around." The CEO stated the most important objective at this point was to find a way to stabilize the facility's financial position. The CEO stated he believed that as of now the financial point of view of the hospital was "not that bad." The CEO stated the facility had changed billing companies in October 2018, and the contracted company had done a "terrible job" and the facility's collections "have fallen off a cliff." The CEO stated the facility was in the process of hiring a different collection company, and was hoping to stabilize and grow the hospital. The CEO stated that he was unaware of the facility's specific budget, stating that would be the responsibility of the CFO.

(Refer to A0043, A0057, A0115, A0145, A0263, A0273, A0385, A0395, A0489, A0490, A0799, A0837, A0940, A0951, A0955, A1100, A1103, and A1104.)

Based on observation, interview, record review, review of the facility's Abuse/Neglect policy, and review of medical records from Facilities #2, #3, and #4 revealed the facility failed to protect six (6) of ten (10) patients from neglect.

Observations revealed the facility provided Emergency Department (ED) services, and surgical services (services were limited to general surgery), and had a twelve (12) bed medical surgical inpatient unit. Interviews revealed the facility did not provide intensive/critical care services and had no policy/procedure in place regarding the scope of services that the medical surgical unit could provide.

Subsequently, the facility admitted Patients #2, #8, and #11 for treatment of diagnoses that the facility could not provide. Patient #2 was admitted with chest pain and to rule out a heart attack even though the facility did not have cardiology services available or an intensive care unit to monitor the patient. The facility failed to conduct heart testing, blood pressure monitoring, and laboratory testing to monitor the patient's cardiac status as ordered by the patient's physician. When the patient developed a heart arrhythmia, the facility failed to notify the patient's physician timely and Patient #2 was not transferred to an acute care facility for cardiac assessment and treatment until approximately thirty-four (34) hours after the patient presented to the ED and developed chest pain.

Patient #8 was directly admitted to the medical surgical unit with signs and symptoms of stroke, even though the facility did not have a neurologist or speech/occupational/physical therapy services. The facility failed to follow their stroke protocol and the patient did not receive a Computerized Tomography (CT) scan for approximately one hour after arrival. In addition, the facility failed to administer medications to the patient for treatment of high blood pressure/chest pain, and chronic kidney disease. Interviews revealed staff notified the patient's physician that the patient was having stroke symptoms and the patient's CT scan was a "suboptimal study due to movement artifacts;" however, the physician failed to transfer the patient to another facility for neurological assessment and care until the day after admission. According to the nurse, the physician stated, "Don't call me back anymore. We'll sit on it tonight and transfer [him/her] out tomorrow."

The facility admitted Patient #11 to Surgical Services on 09/21/18 for treatment of Gall Stones with pain, nausea, vomiting, etc. even though the ED physician was "uncertain if anesthesia was available." The consulting Gastrointestinal Physician saw Patient #11 on 09/21/18, and his recommendations were to transfer the patient "where they can do surgery." However, the facility failed to transfer Patient #11 for treatment until 09/24/18, three days later.

In addition, Patient #5 presented to the ED with hip pain on 11/26/18; however, a hip x-ray was not obtained until 11/27/18. The x-ray revealed the patient's hip was fractured; however, the facility did not transfer the patient to obtain treatment for the fracture until 11/28/18. In addition, Patient #5 had physician orders for a regular diet; however, the patient had a feeding tube due to swallowing issues and could not consume a diet by mouth. The facility failed to contact the physician or the Registered Dietitian to ensure the patient received appropriate nourishment and the patient received no tube feeding while the patient was at the facility for approximately two (2) days. Further, the facility failed to assess and treat wounds to the patient's leg and cigarette burns to his/her fingers and failed to administer medications to the patient as ordered by the physician.

Patient #3 presented to the facility's ED on 12/30/18 at 2:35 PM with severe left foot pain and the patient's left foot and little toe were blue in color and cold. At 3:30 PM, the ED physician ordered Lovenox (used to prevent and treat blood clots), Zosyn (antibiotic), and Demerol (medication to treat pain); however, staff failed to administer Lovenox and Zosyn until the next day, approximately twenty-four hours after the medication was ordered. In addition, at 4:13 PM, testing confirmed the patient had a blood clot in an artery in the leg that was blocking blood flow. However, the facility admitted the patient to the facility and did not transfer Patient #3 to a facility that could treat the blood clot until 01/01/19 at 12:00 PM.

Further, the facility admitted Patient #4 for treatment of Congestive Heart Failure and Diabetes. However, the facility failed to administer the patient's Insulin because it was not available at the facility. Then, when the patient's blood sugar was high, the facility failed to notify the patient's physician as ordered of the elevated blood sugars.

The findings include:

Review of the facility's "Patient Abuse or Neglect" policy, approved June 2017, revealed "Patient abuse and neglect is defined as any incident of physical, sexual or verbal abuse, patient neglect or mistreatment." The policy stated employees of the facility were responsible for patient safety and must report any knowledge of patient abuse/neglect. According to the policy, "elder abuse is a term referring to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult."

Observation of the facility on 01/23/19 at 4:30 PM, 01/24/19 at 5:30 PM, and 01/29/19 at 9:00 AM, revealed the facility's inpatient census ranged from three (3) to six (6) on the medical-surgical unit and three (3) to eight (8) in the ED.

Review of physician credentialing files revealed the facility had three Internal Medicine/General Practice physicians and one General Surgeon.

Interview with the Chief Nursing Officer (CNO) on 01/30/18 at 6:20 PM and with the Chief of Staff (COS) on 01/28/19 at 5:00 PM revealed the facility did not provide intensive/critical care services and had no policy/procedure in place regarding the scope of services that the medical surgical unit could provide. Further interview revealed the General Surgeon was not on call at the facility and only conducted scheduled outpatient surgeries one day per week. In addition, the facility did not have anesthesia services available on call and the Radiology Department was not in house from 12:00 AM to 7:00 AM, but was on call.

1. Review of the Emergency Department (ED) record for Patient #5 revealed the patient presented via Emergency Medical Services (EMS) on 11/26/18 and was triaged at 3:35 PM for left leg swelling, pain, and a wound to the left leg that had been present for one week. According to the ED physician's note, Patient #5 sustained a "direct blow" to the left leg "several days ago" and had increased, pain, redness, and swelling since that time.

Review of a Venous Doppler Study of the left leg completed on 11/26/18 at 4:13 PM revealed that Patient #5 was "Positive for DVT" with no compressibility of superficial femoral vein of the left thigh" (Deep Vein Thrombosis or blood clot).

Review of the medical record for Patient #5 revealed the facility admitted the patient on 11/26/18 with diagnoses of Cellulitis of Left Lower Leg (skin infection), Deep Vein Thrombus of Left Thigh (blood clot), and Left Hip Pain.

1.a. Review of Patient #5's History and Physical (H&P) dated 11/27/18 at 11:23 AM revealed Physician #5 documented that "[Patient #5] complains of significant pain in the left hip area." Continued review of the H&P revealed upon examination Patient #5 was "afebrile to touch and in distress due to pain in the left hip area."

Review of a Physical Assessment dated 11/27/18 at 4:00 PM revealed Patient #5 continued to have pain. According to the assessment, the patient had moderate, generalized pain with signs of pain that included diaphoresis (sweating) and restlessness. The assessment revealed pain medication was administered and a follow-up assessment was documented at 5:30 PM; however, the assessment was not completed and the patient's pain level was not documented.

There was no documented evidence that an x-ray of Patient #5's left hip was completed until the day after admission to the facility. Review of Patient #5's physician orders revealed Physician #5 ordered a left hip x-ray on 11/27/18 at 11:00 AM. Review of the left hip x-ray report completed on 11/27/18 at 11:38 AM revealed the clinical indication for the x-ray was "Left Hip Pain; Patient fell out of Bed." Continued review revealed the conclusion was, "Acute relatively undisplaced fracture proximal shaft of femur" (upper thigh bone).

Review of Patient #5's progress note dated 11/28/18 at 9:30 AM and 2:00 PM revealed the patient continued to have moderate left hip pain and pain medication was administered. Review of physician credentialing files revealed no physician was credentialed to conduct surgical repair of a hip fracture. However, there was no documented evidence the facility attempted to transfer Patient #5 for treatment of the hip fracture until 11/28/18, the next day.

According to the Nursing Progress Notes, another acute care hospital was not contacted for transfer until 11/28/18 at 11:30 AM. At 12:00 PM on 11/28/18, Registered Nurse (RN) #2 documented that the facility accepted the patient's transfer and the patient was transferred on 11/28/18 at 3:53 PM by Emergency Medical Services.

Review of the Discharge Summary dated 11/28/18 at 11:32 AM revealed Patient #5 was "Positive for a DVT of left thigh" and had an "acute relatively undisplaced fracture proximal shaft of femur."

Interview with Physician #5 on 01/29/19 at 4:35 PM revealed that he knew Patient #5 well and when he examined the patient the day after admission, he found the patient to be in pain. Physician #5 stated that because it was difficult to communicate with Patient #5, he often ordered radiological studies to rule out any broken bones. Physician #5 stated when Patient #5's x-ray was positive for a fracture of the femur, he contacted a General Surgeon who used to work with him at the facility. Physician #5 stated that to his knowledge, surgeons conducted orthopedic repairs. Continued interview revealed that when he was notified the next day that the physician could not do the repair, he arranged for Patient #5 to be transferred to another acute care facility.

Interview with the Discharge Planner on 01/24/19 at 4:24 PM revealed she was familiar with Patient #5 because the patient was discharged from the hospital. She stated she spoke with Physician #5 regarding the timeframe for transferring the patient. According to the Discharge Planner, Physician #5 attempted to transfer Patient #5 on 11/27/18 to a physician that he used to work with; however, the physician did not get back to him until 11/28/18 and told him he did not have the "right equipment at the facility he worked at now and he could not accept the patient." At that time, Physician #5 arranged to transfer the patient to another acute care facility that provided orthopedic surgery. The Discharge Planner stated she was surprised that Physician #5's first attempt to transfer was to a "Critical Access Hospital" and was to just a "General Surgeon," not an "Orthopedic Surgeon."

1.b. Review of the ED physician's note dated 11/26/18 at 5:23 PM for Patient #5 revealed the patient's abdomen was soft and non-tender. Further review of the ED record revealed Patient #5 was admitted for further evaluation due to DVT, abrasion, and cellulitis to the left lower leg and hypokalemia. According to the Patient Progress Notes dated 11/26/18 at 8:18 PM, Patient #5 weighted ninety-five (95) pounds on admission, and review of admission orders dated 11/26/18 revealed an order for a regular diet.

However, a review of the Initial Physical Assessment dated 11/26/18 at 8:29 PM revealed Patient #5 was at risk for aspiration due to difficulty swallowing and chewing and was fed by a feeding tube. Further review revealed the patient had facial weakness and received enteral nutrition (feeding tube). The assessment then referred to a "nutrition E-Form" for nutrition information. However, there was no documented nutritional information. Further, there was no evidence that staff notified the physician that the patient could not consume an oral diet and obtained orders to feed the patient via the patient's feeding tube.

Review of Patient #5's Progress Notes revealed staff documented the patient had no intake (food or tube feeding) on 11/27/18 at 8:07 AM, 12:31 PM, 5:49 PM, 10:19 PM, and 11/28/18 at 6:32 AM. On 11/28/18 at 8:00 AM, an RN documented that good nutrition and adequate fluid intake was encouraged, even though staff documented on admission that the patient had a feeding tube with trouble swallowing.

Interview with the Registered Dietitian (RD) on 01/29/19 at 1:30 PM revealed he should assess all patients who had a feeding tube or wounds to ensure they were receiving adequate nutrition to meet the patient's needs. However, the RD stated staff did not notify him that Patient #5 had a feeding tube and he had not assessed the patient. According to the RD, the facility had only requested a consultation for one patient during the approximately eight months that he had been contracted with the facility. The RD stated he was unsure why the facility did not consult him for clinical consultation.

Interview with the Dietary Manager on 01/24/19 at 11:10 AM revealed she did not consult the RD related to inpatients' needs due to facility budget contraints.

Interview with Registered Nurse (RN) #2 on 01/24/19 at 2:30 PM revealed he was not sure why Patient #5's physician was not contacted for tube feeding orders.

Interview with the Assistant Chief Nursing Officer (ACNO) and the CNO on 01/30/19 at 6:00 PM revealed all patients with a feeding tube should have a physician's order to address the patient's nutritional needs. They stated it was the expectation of the facility that each patient would be fed, unless there was an order to be NPO (nothing by mouth).

1.c. Review of the facility policy titled "Medication Administration," dated August 2017, revealed staff should provide care, treatment, and services using the most current physician orders. The policy stated the definition of "STAT" when used with medication orders meant the medication should be administered within fifteen (15) minutes of the order.

Review of Patient #5's potassium level dated 11/26/18 at 4:20 PM revealed the patient's level was low at 2.7 (normal is 3.5 to 5.3). Review of physician orders dated 11/26/18 at 5:09 PM, revealed potassium was ordered "STAT." According to Patient #5's History and Physical (H&P) the patient had "life threatening hypokalemia [low potassium] which will be supplemented." However, review of Patient #5's Medication Administration Record (MAR) revealed Potassium was not administered until 11/26/18 at 6:56 PM (one hour and forty-seven minutes after it was ordered to be administered STAT).

Further review of Patient #5's physician orders revealed the following medications were ordered to be given "STAT" (immediately): Lovenox 90 mg injection (treats and prevents blood clots) was ordered at 11/26/18 at 4:44 PM; Zofran 4 mg (used to treat nausea and vomiting) intravenously (IV); and Morphine 4 mg IV was ordered on 11/26/18 at 5:02 PM.

However, review of Patient #5's Medication Administration Record (MAR) dated 11/26/18 revealed the facility did not administer the patient's medications STAT as required by the facility's protocol. Lovenox was not administered until 11/26/18 at 5:30 PM (45 minutes after the medication was ordered); and Zofran and Morphine were not administered until 11/26/18 at 6:56 PM (one hour and fifty-four minutes after it was ordered).

Interview with Registered Nurse (RN) #8 on 01/28/19 at 10:30 AM revealed that she recalled Patient #5 presenting to the ED with a swollen leg and was diagnosed with a DVT. RN #8 stated the patient's medications were administered late because she did not have a needle that was needed to access the patient's port-a-cath (a catheter that is inserted in a large vein above the heart). RN #8 stated the ED had been out of the needles for "some time." RN #8 stated she attempted to start an IV on the patient two (2) times, but was unsuccessful and waited for another nurse to start an IV for the patient. RN #8 stated that she could not recall whether she notified the physician that Patient #8 had not received the medications STAT (within 15 minutes).

1.d. Review of the facility's Skin Integrity/Pressure Ulcer policy, approved August 2018, revealed the purpose of the policy was to ensure all patients admitted to the facility were assessed for skin integrity.

Review of the Plan for Assessment and Reassessment of Patients policy, approved February 2017, revealed patient assessments were initiated upon admission and continued throughout the patient's stay. The goal of patient assessment and reassessment was to determine the type and kind of care the patient required initially, the follow-up and response to that care, and frequent evaluations for changes in patient status and needs in order to change the plan of care.

Review of the Emergency Department (ED) Record for Patient #5 revealed he/she presented via Emergency Medical Services (EMS) on 11/26/18 and was triaged at 3:35 PM for left leg swelling, pain, and a wound to the left leg that had been present for one week.

Review of the ED physician's note dated 11/26/18 at 3:48 PM revealed Patient #5 was paralyzed on the left side as a result of a prior stroke. The note also stated the patient had hit his/her leg against the wheelchair several days ago and had an abrasion on the left lower leg.

Review of a skin assessment completed in the ED on 11/26/18 at 4:02 PM revealed Patient #5's left lower extremity was red and swollen with a 5.5 by 1 centimeter open wound to the left lower extremity. The nursing note stated the wound bed was red with areas of yellow granulation and the wound edges were black. The note stated no drainage or odor was noted.

Further review of the ED record revealed Patient #5 was admitted for further evaluation due to DVT, abrasion, cellulitis to the left lower leg, and hypokalemia.

Review of Patient #5's initial nursing assessment dated 11/26/18 at 8:29 PM revealed staff documented that the patient had a skin tear with yellow granulation to the left lower leg with redness and edema around the area. According to the patient progress note dated 11/26/18 at 10:37 PM, a dressing to the left lower leg completed in the ED at 4:00 PM was intact.

Review of Patient #5's History and Physical (H&P) dated 11/27/18 at 11:23 AM revealed the patient had cigarette burn marks on the right middle finger and the right ring finger and an abrasion and cellulitis of the left lower leg. There was no documented evidence that the burns had been identified during the admission nursing assessment. In addition, the H&P stated the plan was to do wet to dry dressings and apply Silvadene cream to the right hand; however, the treatment was never completed while Patient #5 was at the facility.

Further review of Patient #5's medical record revealed no documented evidence the facility reassessed the wound to the patient's left lower leg or the patient's fingers and no evidence treatment was provided to the areas. Review of patient progress notes dated 11/28/18 at 8:10 AM and 8:00 PM, revealed Patient #5 had no dressings to the skin, had no edema, and the patient's skin was within normal limits.

Interview with Registered Nurse (RN) #8 on 01/28/19 at 10:30 AM revealed she could not recall if Patient #5 had an open wound or not; however, she stated that she had never taken pictures of wounds or pressure sores; or documented a detailed description of the pressure ulcer as an RN in the ED.

Interview with the Assistant Chief Nursing Officer on 01/30/19 at 6:00 PM revealed that it was the expectation of the facility for all nursing staff to follow facility policies. The Assistant CNO stated it was the policy of the facility for all wounds to be pictured, documented on a wound care sheet, and to have a treatment ordered.

Interview with RN #2 on 01/24/19 at 2:30 PM revealed that he could "kind of" recall Patient #5. RN #2 stated that he did not know what happened with Patient #5 or why he/she remained in the facility after they were aware the patient's hip was broken. Further, RN #2 did not know why there was no assessment of Patient #5's leg or finger wounds and did not recall Physician #5 ordering any type of treatments to be provided to the wounds.

Interview with the Assistant CNO on 01/28/19 at 4:00 PM revealed that she was unware of the facility failures regarding Patient #5 not receiving medications in a timely manner; not receiving wound care; not receiving g-tube feeding; and no order regarding feeding until they were brought to her attention at the time of this survey. Continued interview with the Assistant CNO revealed that currently Quality Review of Nursing Documentation and ensuring Physician orders were being completed was not being conducted.

Review of the medical record for Patient #5 from Facility #2 revealed Facility #2 admitted Patient #5 on 11/28/18 with a "left femur fracture following a fall." Review of the History & Physical for Patient #5 revealed the patient had the following: Acute Undisplaced Fracture Proximal Left Shaft of Femur, Left Superficial Femoral Vein DVT, Cellulitis, and Ulcer of the Left Lower Extremity, CVA with Left Hemiparesis, Dysphagia Status Post PEG Tube Placement, Bedbound, and Probable Physical Abuse by family. The hospital plan was to admit the patient, tube feeding, orthopedic consult, IV antibiotic, wound care consult, and case manager consult for possible Adult Protective Services consultation.

Further review of the Discharge Summary revealed the facility discharged Patient #5 on 12/03/18 to a long-term care facility with discharge diagnoses "Underweight plus mild malnutrition." According to the record, the patient's weight was 99 pounds on discharge.

2. Review of Patient #2's medical record revealed the patient presented to the facility Emergency Department (ED) via ambulance on 10/10/18 at 7:58 AM with Syncope (temporary loss of consciousness usually related to insufficient blood flow to the brain) and a left arm injury. A review of the ED physician's note dated 10/10/18 revealed the physician examined Patient #2 at 8:11 AM and documented the patient had two syncopal episodes that morning after standing. The note stated the patient lost consciousness and collapsed. The note further stated the patient had sustained a wrist fracture the night before after sustaining a fall.

A review of the ED physician's note dated 10/10/18 at 8:28 AM, revealed Patient #2 developed chest discomfort and an EKG (a test of the heart's electrical activity used to detect heart conditions) was obtained. According to the note, the patient's EKG was unchanged when compared to a previous EKG completed in July 2018. In addition, the patient's Troponin (an elevated troponin level may indicate some degree of damage to the heart) was within normal limits.

Further review of the physician's notes for 10/10/18 at 9:36 AM revealed Patient #2 was stable and the chest discomfort was relieved by nitroglycerin.

Review of physician orders dated 10/10/18 at 11:34 AM revealed Patient #2 was being admitted to Physician #7's care for observation due to chest pain with syncope and to rule out a myocardial infarction (MI or heart attack).

Review of Physician Orders for Patient #2 dated 10/10/18 at 11:35 AM revealed an order to repeat a test of the patient's Troponin level and conduct another EKG at 1:00 PM and 5:00 PM on 10/10/18 due to chest pain. However, there was no documented evidence the facility obtained an EKG or Troponin level at 1:00 PM on 10/10/18. The facility completed the tests at 5:00 PM and the patient's Troponin level was within normal limits and the EKG showed a normal rhythm with an "abnormal" EKG.

Further review of physician orders dated 10/10/18 at 5:50 PM revealed an order to conduct orthostatic blood pressures the next morning (10/11/18) (process of taking a patient's blood pressure while lying, sitting, and standing. An abnormal decrease in blood pressure when a person stands up can cause syncope). However, there was no documented evidence the facility conducted orthostatic blood pressures.

Further review of physician orders dated 10/11/18 at 9:55 AM, revealed an order to obtain an EKG "STAT" for Patient #2. A review of the EKG report dated 10/11/18 at 10:14 AM revealed Patient #2's heart rate was 80, and the patient had developed atrial fibrillation (an irregular and often rapid heart rate that can increase your risk of stroke, heart failure, and other heart-related complications) and continued to show acute ischemia. Further, a repeat EKG dated 10/11/18 at 10:19 AM, four minutes later, revealed the patient's heart rate was 92, and the patient continued to have atrial fibrillation and acute ischemia. However, there was no documentation that Patient #2's physician was notified that the patient had developed atrial fibrillation.

Review of a nursing note dated 10/11/18 at 10:45 AM revealed Registered Nurse (RN) #2 documented that when transferring Patient #2 to bed after having an x-ray, the patient had a syncopal episode and became diaphoretic (sweaty) and hypotensive (low blood pressure). The nursing note stated the patient's physician was notified and a new order was obtained. Review of a physician order dated 10/11/18 at 11:15 AM revealed an order to conduct another EKG. According to the nursing notes dated 10/11/18 at 11:19 AM, an EKG was obtained, the patient was in atrial fibrillation, and the patient's physician was notified. However, there was no documented evidence that another EKG was obtained.

Further review of Patient #2's nursing notes revealed at 1:43 PM on 10/11/18, staff documented that the patient was having atrial fibrillation, "went into asystole (no heart beat), and converted to sinus rhythm." The nurse documented that the patient was sitting up in bed with no distress. According to the note, Patient #2's physician was notified and the physician requested the patient be transferred to another facility with cardiology.

Further review of Patient #2's medical record revealed on 10/11/18 at 4:10 PM, staff documented that the patient heart rate was 69 and the patient was having Premature Ventricular Contractions (PVC) (irregular heartbeat); however, there was no further documentation of an assessment of the patient's condition. According to a nursing note dated 10/11/18 at 4:30 PM, Emergency Medical Services (EMS) was notified of the need to transport Patient #2 and the patient left the facility with EMS at 6:00 PM on 10/11/18 for transport to Facility #4.

A review of Patient #2's Discharge Summary revealed Physician #7 documented that the patient "evolved" to atrial fibrillation with "pause" and was transferred "in case need pacer [pacemaker]".

Interview with RN #7 on 01/28/19 at 2:35 PM revealed that she really could not recall specifics about Patient #2; however, she did state that she was the RN that took verbal orders for the patient from Physician #7. RN #7 stated that Physician #7 was bad to come back and "add" orders and could see how some of those orders for Patient #2 were missed. RN #7 stated that evidently nursing staff had just missed the 1:00 PM orders for an EKG and troponin level.

Interview with RN #2 on 01/29/19 at 5:20 PM revealed he did not recall taking care of Patient #2 on 10/11/18. RN #2 stated he did not know why the EKG or the Troponin level was not done at 1:00 PM or why orthostatic blood pressures had not been taken. Continued interview with RN #2 revealed that he felt certain that he had spoken with Physician #7; however, he could not recall what he was told nor was there any documented evidence that he had contacted the physician.

Interview with the Assistant Chief Nursing Officer (CNO) on 01/28/19 at 4:00 PM revealed that she did not know why the EKG and troponin level were not completed. The Assistant CNO stated that RN #2 failed to document according to facility policy and failed to ensure physician orders were followed. Continued interview with the Assistant CNO revealed that currently Quality Review of Nursing Documentation and ensuring Physician orders were being completed was not being conducted.

An interview was requested with Physician #7; however, he declined.

Review of Patient #2's medical record from Facility #4 revealed Facility #4 admitted Patient #2 on 10/11/18 with diagnoses that included Syncope, Atrial Fibrillation, Coronary Artery Disease, Hyperlipidemia, Dementia, Essential Hypertension, and Closed Fracture of the Left Wrist. Patient #4 had a heart catheterization (a procedure where a catheter is inserted to check the vessels of the heart) on 10/12/18 along with an Echocardiogram (a procedure that uses electrodes to check your heart rhythm and ultrasound technology to see how blood moves through your heart). Facility #4 made recommendations for medical management of Atrial Fibrillation for Patient #4 and started the patient on a low dose of Sotalol (a medication used to assist with rhythm disturbances of the heart). Facility #4 discharged Patient #2 home on 10/13/18 with Home Health and follow-up appointments.

3.a. Interview with the Assistant Chief Nursing officer (ACNO) on 01/28/19 at 4:00 PM revealed the facility did not have a policy/procedure/protocol regarding the scope of care the facility could provide for patients admitted to the medical surgical unit of the facility. However, the ACNO acknowledged the facility did not have the ability to care for patients with a diagnosis of Acute Cerebrovascular Accident (CVA/Stroke), or patients who were having difficulty swallowing or signs of Aspiration. The ACNO stated the facility did not have a neurologist, physical/occupational/speech therapy, etc. to care for a patient with a diagnosis of Cerebrovascular Accident (CVA/stroke) on an inpatient basis. Further, the ACNO stated the facility's Acute Stroke Practice Standard for the facility's Emergency Department should also be implemented when an inpatient had signs/symptoms of a stroke.

Review of the facility's policy, Acute Stroke Practice Standard for the Emergency Department (ED), undated, revealed patients exhibiting signs and symptoms of a stroke should receive imaging including a non-contrast head computed tomography (CT) scan within twenty (20) minutes of arrival.

Review of Patient #8's medical record revealed Physician #7 evaluated the patient in his office on 01/21/19, and the patient was admitted directly to the medical surgical unit with diagnoses that included Acute CVA (cerebrovascular accident/stroke), Old CVA, and a recent fall with Concussion, even though the facility did not have the capability to treat a patient who was having a stroke.

Further review of Patient #8's record revealed the patient was not oriented to person or place, and the patient was confined to bed. The patient also had diagnoses that included Phosphatemia (presence of phosphate in the blood), Chronic Kidney Disease Stage 4, and a surgical history of a left nephrectomy (removal of a kidney).

The admission nursing assessment dated 01/21/19 revealed the patient arrived at the medical surgical unit at 5:25 PM. The patient was "disoriented x 3," attempting to eat, "but holding a Kleenex to [his/her] mouth and stated [he/she] was having trouble swallowing." The patient's spouse also informed staff the patient "has been unable to walk or communicate with him today." The patient was unable to do "pushes or grips" during neurological assessments, and was "very weak on the right side, mouth drooping noticed on [his/her] right side."

Interview with Registered Nurse (RN) #7 on 01/24/19 at 3:10 PM revealed she admitted Patient #8 to the facility on 01/21/19 and stated, "I was worried about what I was dealing with." She stated the patient was drooling, hand grips were not equal, and the patient had visible deficits that were signs of a stroke. She also stated she did not feel like the patient's needs could be met at the facility. RN #7 stated at times she felt physicians admitted patients that did not receive the level of care they required.

Based on observation, interview, record review, and review of the facility's Quality Management Manual and Performance Indicators it was determined the facility failed to have a Quality Assurance/Performance Improvement (QAPI) Program to measure, analyze, and track quality indicators and other aspects of performance to assess processes of care, hospital services, and hospital operations. Review of Performance Indicators revealed the facility failed to conduct QAPI activities during the last quarter of 2018 and interviews revealed no QAPI activity had occurred since the Director of QAPI resigned in July 2018. Subsequently, review of patient records and interviews with staff revealed the facility failed to identify patient safety concerns and failed to develop action plans to address the concerns to prevent reoccurrence.

The findings include:

Review of the facility's Quality Management Manual dated June 2015 revealed the facility implemented a Quality Management System that documents the facility's basic policies and processes to achieve customer satisfaction while continually improving quality. The manual stated the facility's quality policy was dedicated to providing world class, comprehensive healthcare in the most compassionate and cost effective manner. According to the manual, the Chief Quality Offer was the Management Representative and had responsibilities that included ensuring that the processes for quality management were established and implemented, and reporting the facility's performance. The manual further stated the facility's Quality Management plan addressed key performance improvement focus areas. The facility provided the Key Performance Indicators for 2018; however, interview with the Chief Nursing Officer on 01/30/19 at 6:20 PM and with the Assistant Chief Nursing Officer on 01/30/19 at 6:20 PM revealed the facility had not been conducting quality reviews nor had a Quality Meeting (Performance Improvement) since October 2018.

1. Review of Patient #3's medical record revealed the patient presented to the facility Emergency Department (ED) on 12/30/18 at 2:35 PM with severe left foot pain and the patient's left foot and little toe were blue in color and cold. At 3:30 PM, the ED physician ordered Lovenox (anticoagulant-used to prevent and treat blood clots), Zosyn (antibiotic), and Demerol (narcotic medication to treat pain); however, staff failed to administer Lovenox and Zosyn until 12/31/18, approximately twenty-four hours after the medication was ordered. In addition, Demerol was not administered until 6:00 PM, on 12/30/18, approximately three hours after it was ordered.

In addition, review of Patient #7's medical record revealed the patient was admitted on 01/06/19 with Cellulitis to the right lower extremity (skin infection), early sepsis (a potentially life-threatening condition caused by the body's response to an infection), and a Stage 2 pressure sore. Patient #1's physician ordered Lovenox (anticoagulant) medication on 01/06/19 for the patient to prevent blood clots; however, there was no documented evidence the facility administered Lovenox until 01/07/19, approximately twenty-two (22) hours later.

Patient #8 was directly admitted to the medical surgical unit on 01/21/19, with signs and symptoms of stroke. The facility failed to administer physician ordered medications that included Cardizem (treats high blood pressure/chest pain), Renvela (phosphate binding drug for patients with chronic kidney disease), or Biotin (water-soluble B vitamin) on 01/21/19 and/or 01/22/19 as ordered by the patient's physician.

Review of the facility's formulary revealed Cardizem was listed; however, Interview with Registered Nurse (RN) #3 on 01/22/19 at 8:20 PM revealed the medication was not available. Further review of the formulary revealed Renvela and Biotin were not on the formulary; however, there was no documented evidence that the patient's physician was contacted regarding obtaining the medication or ordering a substitute.

Review of Patient #4's medical record revealed the facility admitted the patient on 01/22/19 for treatment of Congestive Heart Failure and Diabetes with physician orders to administer insulin. However, the facility failed to administer the patient's Insulin on 01/22/19 because it was not available at the facility. There was no documented evidence that the facility notified the patient's physician that the medication was not available and insulin was not administered. Subsequently, further review of Patient #4's medical record revealed Patient #4's blood sugar was elevated on 01/22/19 and 01/23/19; however, there was no documented evidence the facility notified the patient's physician as ordered when the patient's blood sugar was above two-hundred. Further review of the patient's medical record revealed on 01/23/19 at 8:15 AM, Patient #4's physician ordered a potassium supplement "now", discontinued the patient's Lasix medication. However, review of the patient's medication administration record dated 01/23/19 revealed the facility failed to administer the potassium supplement until 5:17 PM, nine hours after the "now" order. In addition, the facility administered Lasix on 01/23/19 at 5:12 PM, even though the medication was discontinued. In addition, there was no documented evidence the facility contacted the patient's physician with the patient's urinary output on 01/22/19, as ordered by the patient's physician.

Review of the facility's Performance Indicators for 2018 revealed the facility was required to monitor medication variances that included medications that did not reach the patient (eight in the fourth quarter 2018), and patients responsible for their own medication (none for the fourth quarter 2018). In addition, the facility was required to monitor the following situations for Pharmacy services: percentage of times antibiotics were administered within the one-hour window (85% in the fourth quarter); percentage of time diabetic medications were administered within the one-hour window (65.1% in the fourth quarter); and percentage of times anticoagulants were administered within the one-hour window (81.2% in the fourth quarter). The facility's threshold was 100%. There was no documented evidence the facility had implemented an action plan to ensure medications were available for patients and were administered per physician orders.

Interviews with RN #7 on 01/24/19 at 3:10 PM, RN #4 on 01/24/19 at 5:20 PM, RN #3 on 01/22/19 at 8:20 PM, RN #2 on 01/24/19 at 1:50 PM, and with RN #11 on 01/29/19 at 6:45 PM revealed they never knew if the facility had physician ordered medications available. The RNs stated when a medication was ordered, they had to "hunt" in the facility to locate the medication, if they could find the medication at all. The RNs stated "hunting" for medications often caused a delay in treatment. RN #3 stated, "not having the medications we need here happens so often, it's just became a normal occurrence..."

Interview with Pharmacist #1 on 01/23/19 at 2:45 PM revealed she continued to review Medication Administration Records and track medication errors as part of the facility's Performance Improvement program. She stated she also tracked whether antibiotics, diabetic medications, and anticoagulants (blood thinners) were administered in a timely manner. The pharmacist stated however, that if nursing staff did not circle a medication when it was not administered or notify pharmacy that a medication was not given for any reason (unavailable), then she did not track those medications and they were not currently counted as medication errors. The pharmacist stated she had not identified that patients were not receiving medications as ordered or that medications were being administered late due to the unavailability of medications. Further interview revealed the facility had trouble obtaining medications because of a past due debt with the Pharmacy Distributor. The pharmacist stated she monitored medication stock, but could only order medications as the budget allowed; however, there was no documented evidence that staff had been educated about medication shortages/unavailability or that the facility was monitoring to ensure patients received ordered medications, or at least equivalent substitutes. In addition, the Director of Pharmacy stated pharmacy services were routinely discussed during Pharmacy and Therapeutics (P&T) Committee quarterly; however, there had not been a P&T Committee meeting since July 2018, when the physician that led the Quality Committee resigned.

Review of the facility's Pharmacy and Therapeutics Committee Meeting Minutes revealed the committee had not met since 07/18/18. Review of the 04/10/18 minutes revealed twenty-eight medications/Intravenous (IV) Solutions were listed as "drug shortages." There was no documentation regarding why there were drug shortages or what actions the facility took to obtain the medications/substitutes. Review of the 07/18/18 minutes revealed drug shortages were "unable to determine due to lack of drug orders being placed."

Review of emails revealed effective 01/24/19, the facility did not have a Retail Pharmacy Vendor to supply medications to the facility. According to the email, the retail pharmacy was "turning over the handling of outstanding amounts to our legal team and will no longer be able to service the account." Observation, interview, and record review revealed the facility failed to have medications that were required by the facility's formulary, including antibiotics, intravenous fluids, and medications required for emergencies. In addition, observation and interview revealed the facility's Verapamil and Epinephrine (drugs used in emergencies) expired on 01/31/18, and the facility only had one vial of Activase (used to treat blood clots in patients having heart attacks and strokes). Interviews revealed the facility was unsure how they were going to obtain medications for use at the facility.

2. Review of the facility's Performance Indicators for 2018 revealed the facility monitored Surgical Services quarterly. The monitoring included ensuring procedures matched patient consent forms. According to the 2018 data, one hundred percent of the procedures matched the patient's consent form. However, review of a "Variance Report Investigation" dated 08/16/18 revealed the facility was aware that Patient #1 received a colonoscopy (a procedure to examine the colon from the rectum) "in error." Patient #1 had consented for an EGD (esophagogastroduodenoscopy is a procedure to examine the stomach and upper portion of the small intestine). Review of the patient's medical record revealed staff documented that a "time out" occurred and the patient's procedure was confirmed. According to the investigation, the RN "believes" he initiated the time out procedure for an EGD; however, the room had been set up with equipment for a colonoscopy and "with no objections from any team members, an attempted colonoscopy was performed." The investigation revealed the Operating Room technician stated that the time out was conducted; however, staff stated the patient was supposed to have a colonoscopy. The CRNA initially stated the time out was conducted and the RN stated the procedure was supposed to be a colonoscopy, and then changed her mind and said it was supposed to be an EGD.

3. Further review of the facility's Performance Indicators for 2018 revealed the facility monitored the following inpatient care on the medical surgical unit: nutritional assessments, pain management assessment, and pain intervention. However, there was no data documented for the fourth quarter and no evidence the facility was monitoring the quality of care provided to patients in 2019.

Record review revealed Patient #5 presented to the facility's Emergency Department (ED) on 11/26/18 with hip pain and was admitted with a physician order for a regular diet. However, review of the Initial Physical Assessment dated 11/26/18 at 8:29 PM revealed Patient #5 was at risk for aspiration due to difficulty swallowing and chewing and was fed by a feeding tube. Further review revealed the patient had facial weakness and received enteral nutrition (tube feeding). The assessment then referred to a "nutrition E-Form" for nutrition information. However, there was no documented nutritional assessment information. Further, there was no evidence that staff notified the physician that the patient could not consume an oral diet and obtained orders to feed the patient via the patient's feeding tube.

Review of Patient #3's medical record revealed the patient presented to the Emergency Department (ED) on 12/30/18 at 2:35 PM with severe left foot pain. The patient reported that he/she believed his/her foot was broken and the side of the patient's left foot and little toe were blue in color and cold. The patient's physician ordered Demerol (medication to treat pain) 25 mg every four hours as needed on 12/30/18 at 3:30 PM. Review of the Emergency Department Documentation dated 12/30/18 at 3:45 PM revealed Patient #1's pain on a scale of zero to ten was a ten, the worst possible pain. Further review revealed that at 5:15 PM on 12/30/18, Patient #3's pain level was eight. There was no documented evidence that the facility administered medication to treat the patient's pain until 6:00 PM.

Further review of the Performance Indicators for 2018 for the Medical Surgical unit revealed no evidence the facility was required to monitor to ensure care was provided in accordance with physician orders or that physicians were notified of changes in patients' condition. Subsequently, there was no documented evidence that the facility identified that a social services consultation was recommended for Patient #9 on 01/16/19. Review of the patient's record revealed the patient had no running water at home or access to care and medications. However, the facility discharged Patient #9 home with no resources.

In addition, review of Patient #2's medical record revealed the patient was admitted with chest pain and to rule out a heart attack on 10/10/18; however, the facility failed to conduct heart testing, blood pressure monitoring, and laboratory testing to monitor the patient's cardiac status as ordered by the patient's physician on 10/10/18 and/or 10/11/18. When the patient developed a heart arrhythmia on 10/11/18, the facility failed to notify the patient's physician timely and Patient #2 was not transferred to an acute care facility for cardiac assessment and treatment until approximately thirty-four hours after the patient presented to the ED and developed chest pain.

4. Observations on 01/23/19 at 9:45 AM and on 01/30/19 at 5:15 PM revealed the facility provided Emergency Department (ED) services, and Surgical Services (services were limited to general surgery), and had a twelve (12) bed medical surgical inpatient unit. Chief Nursing Officer (CNO) on 01/30/18 at 6:20 PM and with the Chief of Staff (COS) on 01/28/19 at 5:00 PM revealed the facility did not provide intensive/critical care services and had no policy/procedure in place regarding the scope of services that the medical surgical unit could provide. Subsequently, review of medical records revealed the facility admitted Patients #2, #8, and #11 (Patients #2 and #11 were admitted during the fourth quarter 2018; Patient #8 was admitted during the first quarter 2019) for treatment of diagnoses that the facility could not provide and a transfer to another facility was delayed. Patient #2 was admitted on 10/10/18 with a diagnosis of chest pain, to rule out a heart attack, even though the facility had no cardiologist on staff and no intensive care unit.

Review of Patient #11's medical record revealed the patient was admitted to the facility on 09/20/18 with a consult for surgical services, even though the ED physician documented he was unsure if anesthesia services were available. On 09/21/18, the surgeon documented Patient #11 should be transferred to another facility because he did not have the instruments or anesthesia available to treat the patient. However, the facility failed to transfer the patient until 09/24/18, three days later.

In addition, review of Patient #8's medical record revealed the facility directly admitted the patient from a physician's office on 01/21/18 with a diagnosis of Cerebrovascular Accident (CVA or stroke), even though the facility did not have a neurologist on staff, did not have an intensive care unit. In addition, interview with the Director of Pharmacy on 01/23/19 at 2:45 PM revealed the facility only had one vial of Activase. The pharmacist stated she had not had enough of the medication for several weeks, but was unable to order the medication due to the high cost and not enough money in the budget.

In addition, review of Patient #5's hip x-ray report completed on 11/27/18, revealed the patient had a fractured hip. However, there was no evidence the facility transported the patient for treatment of the hip fracture until 11/28/18.

Further, review of Patient #3's medical record revealed CT scans/angiograms on 12/31/18 revealed the patient had a blood clot in the femoral artery of the leg. The facility failed to transfer the patient to receive treatment for the blood clot until 01/01/19, and allowed the patient to go by private vehicle.

Review of the facility's Performance Indicators for 2018 revealed the facility monitored Case Management indicators that included the number of transfers to a facility that provided equal or a greater level of care and average length of stay. Review of the facility data for the fourth quarter of 2018 revealed four (4) patients had been transferred and the average length of stay was four days. There was no documented evidence that the facility identified any concerns with transfers and took any action to ensure patients were transferred timely.

5. Review of the facility's Performance Indicators for 2018 revealed the facility was required to monitor Radiology delays in service and call backs for radiology services; however, there was no data documented for the fourth quarter of 2018 and no documented evidence that the facility was monitoring performance in 2019.

Review of Patient #12's medical record revealed the patient arrived at the facility's ED on 12/04/18 at 8:02 PM unresponsive and in full cardiac arrest (unconscious with no heart function or breathing) with cardio pulmonary resuscitation (CPR) in progress upon arrival. Review of physician orders for Patient #12 dated 12/04/18 at 9:10 PM, revealed the ED physician ordered Patient #12 to have a chest x-ray obtained "STAT" (immediately). However, review of Patient #12's medical record revealed no evidence the chest x-ray was obtained as ordered.

Interview with Registered Nurse #13 on 01/30/19 at 2:30 PM revealed she could not state emphatically why Patient #12 did not get the chest x-ray as ordered, but stated there was no one from the Radiology Department present in the facility while Patient #12 was receiving treatment. Review of the Radiology Department's schedule confirmed that staff were not scheduled, but were on call from 12:00 AM until 7:00 AM; however, there was no evidence the facility was monitoring to ensure staff were providing timely services.

6. Review of Patient #4, #5, and #7's medical records and interview with the Dietary Manager on 01/24/19 at 11:10 AM revealed the facility failed to have a system for consulting the Registered Dietitian (RD). According to the Dietary Manager, staff did not consult the RD due to budget constraints.

Review of Patient #5's medical record revealed the patient was admitted on 11/26/18, with an order for a regular diet, and a weight of ninety-five pounds. However, further review of the record revealed the patient had a feeding tube and received no nutritional intake during the patient's admission from 11/26-28/18. There was no documented evidence the facility consulted the RD for Patient #5 to ensure the patient's nutritional needs were assessed and tube feeding was recommended to ensure the patient's needs were met.

In addition, review of Patient #7's medical record revealed the facility failed to ensure the RD consulted on Patient #7 who was admitted on 01/06/19 with a diagnosis of Cellulitis and a Stage 2 pressure sore.

Further, Patient #4 was admitted to the facility on 01/22/18 with a diagnosis of Diabetes. Review of the patient's physician orders revealed an order to administer insulin daily and an order to provide a no concentrated sweets diet. However, there was no documented evidence the facility administered the insulin on 01/22/19. In addition, observation on 01/23/19 at 4:30 PM revealed the resident was receiving a regular diet. There was no documented evidence the facility consulted the RD to assess Patient #4.

Interview with the RD on 01/29/19 at 1:30 PM revealed he had only consulted on one patient in the approximately eight months that he had been contracted with the facility.

Review of the facility's Performance Indicators for 2018 revealed the facility was required to monitor to ensure Registered Dietitian consultations occurred within forty-eight hours of being ordered; however, there was no data documented for the first, third, or fourth quarters, and there was an "x" in the second quarter. In addition, there was no documented evidence that staff were monitoring to ensure dietary consultations were completed in 2019.

7. Review of Patient #12's medical record revealed the patient presented to the ED on 12/04/18, in full cardiac arrest. On two different occasions, Patient #12 required multiple doses of Epinephrine (a medication to stimulate the heart) in an effort to sustain the patient's life. However, the facility failed to have enough medication to treat the patient, and medication had to be supplied to the facility by the Emergency Medical Services (EMS) that had transported the patient to the ED. Observation of the facility's ED on 01/30/19 at 5:00 PM revealed four (4) ampules of Epinephrine were available for an adult patient and four (4) ampules of Epinephrine for a pediatric patient. However, all eight ampules of Epinephrine had expiration dates of 01/31/19, the next day. Further, the facility had no available Epinephrine to replace the expired Epinephrine and could not purchase any medication because their Pharmacy Distributor stopped releasing medication to the facility due to unpaid debt.

Review of an audio recording dated 07/17/18, revealed EMS was attempting to transfer a patient to the ED who was exhibiting signs and symptoms of an acute stroke. However, when EMS contacted the ED to inform them that they were in route with the patient, they were informed by RN #11 not to bring the patient to the ED because they would "kill this guy." Subsequently, EMS contacted a transport helicopter and the patient was flown to another facility.

Further, the facility had an "Acute Stroke Practice Standard for the Emergency Department" in place with specific criteria and interventions for the medical staff to follow and implement when a patient presented to the Emergency Department (ED) with signs/symptoms of a stroke. However, the facility failed to implement the standard of care on 11/12/18 at 10:35 AM, when Patient #10 presented to the ED with a "significantly elevated blood pressure" and exhibiting signs and symptoms of a stroke. The facility failed to implement their Acute Stroke Practice Standard for the Emergency Department, and subsequently, Patient #10 did not receive medical imaging including a non-contrast head computed tomography (CT) scan until after being admitted to the medical surgical floor and five (5) hours after arrival to the ED. In addition, the facility failed to administer Patient #10 the stroke scale assessment screening to determine the extent of deficits being experienced by the patient. On 11/12/18 at 4:20 PM, the results of a CT scan of the head for Patient #10 revealed the patient was experiencing an apparent evolving infarct in the right parietal area. The patient was transferred to Facility #6 on 11/12/18 at 8:15 PM for treatment of an acute stroke.

Observation and interview with the Director of Pharmacy on 01/23/19 at 2:45 PM, revealed the facility only had one vial of Tissue Plasminogen Activator (tPA) (name brand Activase), used to treat patients who were having a stroke. Interview with the pharmacist revealed the facility had been unable to purchase the medication in the past because of the high cost of the medication and the facility's budget constraints. However, as of 01/24/19, the facility did not have a Pharmacy Distributor from which to purchase any medication.

Tours of the Emergency Department (ED) on 01/23/19 and 01/30/19 revealed the facility did not have a functioning telemetry monitor (shows the electrical activity of the heart) located at the nursing station, and staff were unable to monitor a patient's cardiac status unless they were present in the patient's room. Further observations revealed eight (8) of nine (9) rooms in the ED did not have a functional pulse oximeter (a device used to measures the amount of oxygen in the blood). Observations in the ED also revealed none of the nine (9) ED rooms contained a functional biohazard "sharps" container. Observation during the tour revealed the only biohazard "sharps" containers located in the ED were located in one hallway and another in the physician's charting room. Observations on 01/30/19 revealed ED staff had to transport used needles and devices through the hallway to get to a biohazard container to dispose of the items. In addition, observation of the casting room on 01/23/19 at 9:45 AM revealed it contained a limited number of supplies necessary to cast fractured bones of patients presenting to the ED in need of casting services. The ED's entire supply of casting tape was expired and the appropriate sizes were not available to treat various injuries.

Further review of the facility's Key Performance Indicators for 2018 revealed the facility was required to monitor the elapsed time from entering the ED until the patient was first seen by a doctor, the percentage of patients admitted, and the percentage of patients receiving a Medical Screening Exam in the Emergency Department (ED). However, there was no documented evidence that the facility had been monitoring the care and services provided in the ED, even though the facility was aware needed medications, supplies, and equipment were not available to provide quality care and services. Further, there was no documented evidence any services provided in the ED were being monitored in 2019.

Interview with the Chief of Staff (COS) on 01/28/19 at 5:00 PM revealed that she had never discussed any quality of care issues with the governing body or the CEO. The COS stated the only conversations she had with the CEO were usually text messages about "When am I (the COS) going to get paid?" The COS stated she had never met the Governing Body of the facility. Continued interview with the COS revealed "at this point" she was not doing any type of chart reviews and had not been in the last six (6) months at least. The COS revealed the last Quality Meeting (Performance Improvement) she attended was in October 2018. She stated she remembered a conversation surrounding Physician #1 performing the incorrect surgical procedure on a patient. However, she was never asked to review the medical record or to speak with Physician #1. Further interview with the COS revealed that she was unaware that the facility only had one (1) Activase vial. She stated she felt that as the COS, and an admitting physician, she should have been informed. The COS further stated that she was not aware the pharmacy had a list of medications that were unavailable and again felt like she should have been notified.

Interview with the Chief Nursing Officer (CNO) on 01/30/19 at 6:20 PM and with the Assistant Chief Nursing Officer (ACNO) on 01/30/19 at 6:20 PM revealed the facility had not had a Quality Meeting (Performance Improvement) since October 2018. The staff stated the Director of Quality Assurance/Performance Improvement (QAPI) resigned in July 2018 and since that time the facility had not been conducting QAPI activities. The CNO and ACNO stated they had not been reviewing nursing documentation for accuracy, physician orders to ensure they were followed, timeliness of medication administration, or other quality review of medical records. The CNO and ACNO stated they were busy with the budget and trying to keep the facility running.

Interview with a Former Governing Body Member on 01/30/19 at 2:07 PM, revealed that she was no longer employed by the facility's corporation and no longer functioned as a governing body member as of "last week." The Former Member stated that there was constant conversation about the facility's finances, and that the cash flow of the facility was always the topic of priority. She stated that she was not aware of a meeting or conversation she had attended or participated in regarding the facility that was not dominated by finances. The Former Member stated she was never involved in or aware of care concerns at the facility.

Interview on 01/30/19 at 2:38 PM with the Chief Executive Officer (CEO) and Owner of the facility, revealed that the Chief Nursing Officer (CNO) and Chief Financial Officer (CFO) functioned as the onsite administration at the facility, and were responsible for the day to day operations. The CEO stated that he had reviewed the facility's quality assurance (QA) program a year ago, but was not aware that the QA Committee had not met since October 2018, and had not been identifying quality concerns in the facility. The CEO stated that he was unaware of any adverse events that had occurred at the facility and had never been informed or discussed that Emergency Medical Services had on occasion had to provide the facility with supplies and assist the ED staff with care of patients due to a shortage of staff and lack of supplies.

(Refer to A0043, A0057, A0073, A0115, A0145, A0263, A0385, A0395, A0489, A0490, A0799, A0837, A0940, A0951, A0955, A1100, A1103, and A1104.)

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure nursing services were provided to supervise and evaluate the care of three (3) of twelve (12) sampled patients (Patients #4, #7 and #8). The facility failed to administer Lovenox (medication to prevent blood clots) for Patient #7 who was admitted on 01/06/19 with Cellulitis to the right lower extremity (skin infection), early sepsis (a potentially life-threatening condition caused by the body's response to an infection), and a Stage 2 pressure sore. The facility also failed to ensure staff assessed the pressure sore and failed to consult the facility dietitian as ordered by the physician.

In addition, Patient #4 was admitted with diagnoses of Acute Congestive Heart Failure (CHF) and Diabetes; however, the facility failed to provide a no-concentrated-sweet diet as ordered by the physician, failed to administer the patient's diuretic medication and potassium supplement as ordered by the patient's physician, and failed to monitor the patient's urinary output.

Further, the facility failed to consult Social Services regarding Patient #7 who did not having running water or access to care, failed to provide the patient the physician ordered diet, and failed to consult the dietitian to assess the patient's wounds and diet.

The findings include:

Review of the facility policy titled "Medication Administration," dated August, 2017, revealed staff should provide care, treatment, and services using the most current physician orders. The policy stated the definition of "Now" when used with medication orders meant the medication should be administered within one (1) hour of the time the medication was ordered. The policy also stated early or late administration of some medications could have a significant or negative impact on the intended pharmacological or therapeutic effect of the medications, which included Anticoagulants, Antibiotics, and Insulins.

Review of the facility's Skin Integrity/Pressure Ulcer policy, approved August 2018, revealed the purpose of the policy was to ensure all patients admitted to the facility were assessed for skin integrity. Review of the Plan for Assessment and Reassessment of Patients policy, approved February 2017, revealed patient assessments were initiated upon admission and continued throughout the patient's stay. The goal of patient assessment and reassessment was to determine the type and kind of care the patient required initially; also to determine the follow-up and response to that care, and frequent evaluations for changes in patient status and needs in order to change the plan of care.

Review of the "Interdepartmental Relationships" policy, approved February 2017, revealed Nursing Services should identify patients who potentially needed a referral to some other agency or nursing facility after discharge, complete documentation as necessary for each referral, and notify Social Services when needs were identified. Further review of the policy revealed nursing staff should notify the dietitian of the need to consult on patients, and were required to coordinate the interdisciplinary plan of care with medical staff.

Review of the facility's policy, "Diets/Meals," approved August 2018, revealed the purpose of the policy was to ensure timely and efficient provision of food and nourishment to patients. The policy did not address when a Registered Dietitian would be consulted. Interview with the Registered Dietitian (RD) on 01/29/19 at 1:30 PM revealed he had a contract with the facility to provide services and should be consulted to assess any patient with a pressure ulcer/wound, tube feeding, or a diagnosis of Diabetes.

1. Patient #7's medical record revealed the facility admitted the patient on 01/06/19 with diagnoses of Cellulitis to the right lower extremity and early sepsis. The patient was also admitted with a Stage 2 pressure sore to his/her right buttock.

Review of Patient #7's admission orders dated 01/06/19 at 1:26 PM, revealed the patient's deep vein thrombosis (DVT/blood clot) prophylaxis, which consisted of a Lovenox (blood thinner) injection forty (40) mg twice daily. Physician orders dated 01/06/19 also revealed staff were required to document the following regarding the patient's Stage 2 pressure sore: the location, size, stage, depth, wound edges, any necrosis, amount of drainage, and condition of the surrounding tissue. A dietary consultation was also ordered when the patient was admitted on 01/06/19.

Further review of Patient #7's medical record revealed staff did not administer Lovenox to the patient until 01/07/19 at 11:30 AM, approximately twenty-two (22) hours after the medication was ordered. In addition, there was no documented evidence that staff assessed the patient's pressure ulcer or consulted a dietitian as required by the patient's physician orders.

Interview with Registered Nurse (RN) #2 on 01/24/19 at 2:30 PM and RN #4 on 01/24/19 at 12:40 PM revealed Lovenox was not available at the facility "at one time" but they could not recall the timeframe or if medication availability was a factor in Patient #4 not getting medication timely.

Interview with the Registered Dietitian (RD) on 01/29/19 at 1:30 PM revealed he was not contacted to assess Patient #7. He stated staff should consult him to assess any patient who had a wound/pressure sore. However, the facility had only requested a consultation for one patient during the approximately eight months that he had been contracted with the facility.

2. Review of Patient #4's record revealed the patient was admitted to the facility on 01/22/19 with diagnoses of Acute Congestive Heart Failure (CHF), Generalized Weakness, and Diabetes.

2.a. Observation on 01/23/19 at 4:30 PM revealed Patient #4 was sitting in a chair eating dinner with family. Patient #4 was observed eating vanilla ice cream. Patient #4's daughter stated the patient was on a "regular" diet, even though the patient had a diagnosis of Diabetes. The daughter showed the surveyor the printed slip that accompanied the patient's meal from Dietary Services with the patient's name that read "regular" diet.

Interview with Registered Nurse (RN) #2 on 01/23/19 at 4:40 PM revealed that Patient #4 was supposed to receive a no-added-salt and no-concentrated-sweets diet. RN #2 stated, however, that "it doesn't matter what diet is ordered; every patient up here gets the same food every meal." RN #2 stated he had not seen any specialized diets on the trays ever. Continued interview with Registered Nurse (RN) #2 on 01/27/19 at 5:00 PM and 01/29/19 at 5:00 PM revealed, "No one here gets a diet other than a regular diet, no matter what's ordered, or what diagnoses they have, even diabetics."

Interview with the Dietary Manager on 01/24/19 at 11:10 AM revealed she doubled checked Patient #4's diet order in the computer and the order was entered into the computer "wrong." The Dietary Manager stated nursing staff had entered no added salt diet; however, they had put "no concentrated sweets" in the wrong section and dietary staff did not see the order. Continued interview with the Dietary Manager revealed that even though "no concentrated sweets" was entered in the wrong place, dietary staff still should have seen the order or at least questioned the order.

2.b. Further review of Patient #4's medical record revealed the patient's physician wrote an order on 01/22/19 for staff to notify him of the patient's urine output over the next two (2) hours. RN #2 signed off the physician's order; however, there was no documented evidence that the RN monitored the patient's urine output two hours after admission or notified the physician of the patient's urine output.

2.c. Continued review of Patient #4's physician orders dated 01/23/19 at 8:15 AM revealed the physician prescribed Potassium twenty (20) milliequivalents (meq) by mouth "now" and discontinued the use of Intravenous (IV) Lasix (a diuretic medication that lowers potassium levels) forty (40) milligrams. However, review of Patient #4's Medication Administration Record (MAR) revealed Potassium was not administered to the patient until 5:17 PM on 01/23/19 (nine hours after the "now" order). Further, staff administered Lasix to the patient on 01/23/19 at 5:12 PM, even though the medication had been discontinued.

Continued interview with RN #2 on 01/29/19 at 5:00 PM revealed he was unsure why he had not administered the patient's potassium "now" per the facility policy, or why he had not discontinued the patient's IV Lasix. The RN also acknowledged he had not notified the patient's physician of the patient's urine output as ordered. RN #2 stated, "I just f...ed that up."

3. Review of Patient #9's medical record revealed the facility admitted the patient on 01/16/19 with diagnoses that included venous stasis disease (slow blood flow in the veins to the legs) with cellulitis (infection) to both lower extremities. Review of Patient #9's admission assessment revealed the patient had weeping malodorous drainage from both lower extremities and the legs were "red with yellow crusty buildup to calf area bilaterally."

According to the medical record, Patient #9 informed staff his/her condition had worsened because he/she had no running water at home, and had no transportation to get to/from scheduled physician appointments or to the pharmacy to get needed medications.

Further review of Patient #9's medical record revealed on 01/16/19 at 5:30 PM a social services consultation was requested. However, further review revealed the facility discharged the patient home on 01/23/19, and there was no documented evidence that Adult Protective Services was ever contacted regarding the patient's inability to obtain medical care.

Further review of physician orders dated 01/21/19, revealed Physician #5 ordered a "2 gm sodium diet" (2 days prior to the patient's discharge) for Patient #9. However, record review revealed the special diet order was not entered into the facility's computer system; subsequently, the Dietary Department did not provide a two gram sodium diet and the patient continued to receive a regular diet during the remainder of the hospital stay.

There was no documented evidence that the Registered Dietitian was consulted for Patient #9, and staff had not educated Patient #9 on the newly ordered diet. The patient was discharged home on 01/23/19 on a regular diet.

Interview with the Registered Dietitian (RD) on 01/29/19 at 1:30 PM revealed he should have been asked to consult on Patient #9 to ensure the patient was receiving appropriate nutrition to heal the patient's wounds.

Interview with the Dietary Manager on 01/24/19 at 11:10 AM revealed she was not a RD and even though the facility had a contract with a RD, she did not consult him related to inpatients' needs. The Dietary Manager stated even if patients had diet changes, pressure sores, or skin integrity impairments, she did not consult the RD "because he charges $140.00 an hour and with the budget we have to operate on, we can't afford him."

Interview with Registered Nurse (RN) #2 on 01/27/19 at 5:00 PM revealed he discharged Patient #9 home on 01/23/19. He stated he had not reviewed the patient's record at the time of discharge and was unaware that Social Services had not been contacted. RN #2 also stated he was unaware that the patient did not have running water at home, or that he/she had no transportation to get to physician appointments or to obtain physician ordered medications. The RN further stated he was not aware Patient #9 had an order for a two gram sodium diet during the hospital stay. According to RN #2, "No one here gets a diet other than a regular diet, no matter what's ordered, or what diagnoses they have, even diabetics."

Interview with the Assistant Chief Nursing Officer (CNO) on 01/29/19 at 11:00 AM revealed medications should be administered as ordered and if physicians ordered social service consultations or diet changes, those orders should be followed. She also stated patients should be educated when special diets were ordered in the facility, and when applicable, the Registered Dietitian should be consulted. She also stated patients should be discharged home with diet instructions that had been ordered by the physician.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to provide pharmaceutical services to meet the needs of patients consistent with the types of patients the facility serves. Interviews and review of emails revealed that effective 01/24/19, the facility did not have a Pharmacy Distributor to supply medications to the facility. According to the email, the distributor was "turning over the handling of outstanding amounts to our legal team and will no longer be able to service the account." Observation, interview, and record review revealed the facility failed to have medications that were required by the facility's formulary, including antibiotics, intravenous fluids, and medications required for emergencies. In addition, observation and interview revealed the facility's Verapamil and Epinephrine (drugs used in emergencies) expired on 01/31/18, and the facility only had one Activase (used to treat blood clots in patients having heart attacks and strokes). Interviews revealed the facility was unsure how they were going to obtain medications for use at the facility.

In addition, Cardizem ER (medication used to treat high blood pressure, abnormal heart rhythms, and chest pain) was on the facility's formulary; however, the facility failed to ensure the medication was available. Patient #8 had an order for Cardizem ER; however, the facility failed to administer the medication because it was not available. In addition, Patient #8 had orders for Renvela (phosphate binding drug for patients with chronic kidney disease) and Biotin (water-soluble B vitamin); however, the medications were not on the formulary and the medications, or a substitute, were not administered to the patient.

Patient #4 had physician orders to receive Victoza (an injectable diabetic medication) 6 milligrams (mg)/1 milliliter (ml) with the ordered dose of 1.2 mg to be administered daily. Interview with staff revealed the medication was not available; however, the facility failed to recognize that the patient was not getting any type of insulin. Subsequently, Victoza was not acquired for Patient #4 and a substitution was not made to ensure the patient received insulin coverage for high blood sugar levels.

The findings include:

Review of the facility policy titled "Formulary System" dated July 2017, revealed the Pharmacy Department would provide a formulary of approved drugs assessed on the basis of need, effectiveness, risk, and cost to assure that medications were readily available for use within the hospital. The policy stated that physicians could also order medications that did not appear on the formulary. According to the policy, the pharmacist or pharmacy technician would attempt to obtain the item and would consult with the physician if the medication was unobtainable or if its procurement would be delayed. If these events occurred, the pharmacist would contact the physician for a "discontinue" or "substitute" order. The policy further revealed the Pharmacist "must communicate medication shortages, if they were to occur, to medical and nursing staff." Then the medical staff, through the Pharmacy and Therapeutics (P&T) Committee, were required to establish a formulary of medications for use within the hospital based on the shortages. According to the policy, the formulary would be reviewed at least quarterly within the hospital.

1.a. Review of Patient #4's record revealed the patient was admitted to the facility on 01/22/19 with Acute Congestive Heart Failure (CHF) and Generalized Weakness. Review of the record also revealed the patient's physician had ordered Victoza 1.2 mg, to be administered daily at 9AM.

However, review of Patient #4's medication administration record revealed the patient's 9:00 AM dose of Victoza for 01/23/19 was not administered.

Review of the facility's formulary revealed Victoza was not listed on the formulary; however, other brands of insulin were available.

Interview with Registered Nurse (RN) #2 on 01/23/19 at 4:40 PM revealed he had not administered Patient #4's Victoza medication because it was not available at the facility. RN #2 stated, "We've battled having medications that we need for a long time. Some things we can't provide to the patients, especially insulin pens. They won't buy them here, they're too expensive I guess."

Interview with Patient #4's wife on 01/23/19 at 5:00 PM revealed the patient was frequently admitted to the facility including two (2) admissions "last month" in December 2018. She stated, "They don't have a lot of medications here that [the patients] are ordered to receive. I try to remember to bring the needed medications, but sometimes I forget." She stated if she forgot the medications, the patient "just has to go without them while we're here."

There was no documented evidence that the pharmacist or technician attempted to obtain Victoza for the patient or contacted the patient's physician for a substitution for the medication in accordance with the facility's policy.

1.b. Review of Patient #8's medical record revealed the facility admitted the patient on 01/22/19 with diagnoses of Acute Cerebrovascular Accident (CVA/stroke), Old CVA, and a recent fall with Concussion, Phosphatemia (presence of phosphate in the blood), Chronic Kidney Disease Stage 4, and a surgical history of a left nephrectomy (removal of a kidney).

Further review of Patient #8's record revealed the patient was not oriented to person or place, and the patient was confined to bed.

Review of Patient #8's physician orders dated 01/21/19 revealed orders to administer Cardizem ER one hundred eighty (180) milligrams (mg) twice daily, Renvela sixteen hundred (1600) mg three (3) times a days, and Biotin one thousand (1000) mg daily.

Review of the facility's formulary revealed Cardizem 60 mg, 90 mg, and 120 mg tablets were listed as being available to administer at the facility. Further review revealed Renvela and Biotin were not listed.

However, a review of Resident #8's Medication Administration Record (MAR) revealed Cardizem was not administered on 01/21/19 at 9:00 PM or on 01/22/19 at 9:00 AM as ordered. Further review revealed Renvela and Biotin were not administered on 01/22/19 at 9:00 AM as ordered. Staff had documented that the medications were "omitted because the medication was absent from the unit." The MAR also stated Biotin was "not on the formulary patient will need to bring own." There was no evidence the facility attempted to obtain Renvela and Biotin medications or notified the patient's physician that the medications were not available.

Patient #8 was transferred from the facility on 01/22/19 and was unable to be interviewed.

Interview with Registered Nurse (RN) #3 on 01/22/19 at 8:20 PM revealed she cared for Patient #8 during the night shift (6 PM-6 AM) on 01/22/19, the night the patient was admitted. She stated the patient had physician orders for Cardizem; however, the medication was not available to be administered. According to RN #3, medication availability was a concern at times and she stated, "If the patients don't bring their home medications with them, they're not able to remain on them, or we have to substitute medications that they're not used to taking."

Continued interview with RN #3 on 01/22/19 at 8:20 PM revealed nursing staff were not aware the facility was unable to provide patients with Cardizem ER, sixty (60) mg or ninety (90) mg. She stated "that would have been useful information."

Interview with Physician #3 on 01/24/19 at 1:50 PM revealed he admitted patients to the facility and had not been notified that the facility was unable to provide Cardizem ER 60 mg or 90 mg to patients in the facility. According to Physician #3, the facility should have notified him of the inability to provide the medication so he could prescribe medications accordingly.

Interview with Pharmacist #1 on 01/23/19 at 2:45 PM revealed "in the beginning of December" she removed all 60 mg and 90 mg Cardizem ER tablets from the facility because they were outdated. She stated there was a nationwide shortage of the medication and she was unable to obtain replacement medication, but had not notified physicians or licensed staff that the medication was not available at the facility. Pharmacist #1 stated if physician ordered medications were not available, nursing staff was responsible for contacting the patient's physician for a substitute. The pharmacist stated she had conducted record reviews of inpatients at the facility and had not identified that patients were not receiving medications as ordered, due to the unavailability of medications. However, she then stated nursing staff were not documenting why medications had been omitted, but no attempts had been made to identify why patients had not received their ordered medications. She stated she had difficulty placing orders for medication with the current pharmacy vendor at times because the facility had consistently failed to make required payments on outstanding debt, which totaled approximately half a million dollars. Pharmacist #1 also stated the Pharmacy and Therapeutics Committee was required to meet quarterly, to discuss medication concerns in the facility, however, the Committee had not met since July 2018, a period of six (6) months.

Review of the facility's Pharmacy and Therapeutics Committee Meeting Minutes revealed the Committee had not met since 07/18/18. Review of the 04/10/18 minutes revealed twenty-eight medications/Intravenous (IV) Solutions were listed as "drug shortages." There was no documentation regarding why there were drug shortages or what actions the facility took to obtain the medications/substitutes. Review of the 07/18/18 minutes revealed drug shortages were "unable to determine due to lack of drug orders being placed."

2. Observation of medications available in the Surgery Department on 01/23/19 at 11:00 AM revealed the following medications were not available: Lidocaine (local anesthetic) 1%, 30 milliliter (ml) vials (par was for 8 vials); Diprivan (short-acting sedative used during surgical procedures; also used to sedate patients mechanically ventilated) 10 mg/ml, 50 ml vial (par was 35 vials); Diprivan 10 mg/ml, 100 ml vial (par was 20 vials); Ampicillin (antibiotic) 2 gm vial (par is 2); Atropine Sulfate (emergency drug for no or low heart rate) 1 mg/ml, 1 ml vial (par is 4); Bupivacaine/Epi .25% (local anesthetic) 30 ml vial (par is 10); Ancef (antibiotic) 1 gm (par is 6); Gentamicin (antibiotic) 80 mg/50 ml IV (intravenous) (par is 4); or Isovue (contrast used in CT scans) 300 (50 ml vial) (par is 6). In addition, the facility surgery department only had eight vials of Lidocaine 1% 10 mg/ml vial (par is 28 vials).

Interview with Certified Registered Nurse Anesthetist (CRNA) #1 on 01/30/19 at 3:00 PM revealed the facility did not have the medications she preferred to use when anesthetizing patients.

3. Interview with the Director of Pharmacy (Pharmacist #1) on 01/23/19 at 2:45 PM revealed the facility pharmacy hours were from 7:00 AM to 3:30 PM. The Director of Pharmacy stated that if a new patient was admitted or a new medication was ordered after hours, staff were required to obtain the medication from the Omnicell (specialized medication dispensing cabinet). The pharmacist stated she stocked the Omnicells with medications before she left for the day. According to the Pharmacist, every Omnicell might not have every medication that was required, but the Omnicell in the Emergency Department had most of the medication that was available to the facility. Continued interview revealed she would come to the facility if needed but stated she could not recall the last time she had been called back into the facility for that reason.

Observation of facility medications in the Omnicell medication supply cabinet on 3 South (Medical Surgical Unit) on 01/25/19 at 12:30 PM revealed forty (40) medications were not available for administration after the pharmacy closed at 3:30 PM. Some of the medications that were not available included: Acetaminophen 325 mg (brand name Tylenol) (par level of 5); Amitriptyline 50 mg (antidepressant) (par level of 5 tablets); Diltiazem 100 mg injectable, 60 mg, 90mg or 120 mg tablets (brand name Cardizem treats high blood pressure/chest pain, heart arrhythmias); Levemir Insulin 100 units/1ML 10ML vial; Novolin R 100 units/1ML 10ML; Ondansetron Oral Disintegrating tablets (Zofran used to treat nausea) (par level of 10 tablets); Phenytoin 25 mg/1 ml 4 ml suspension (Dilantin used to treat and prevent seizures) (par level of 5); Sodium Bicarb 8.4% 50 ML syringe (used in emergencies for cardiac arrest and metabolic acidosis) (par level of 4 syringes); or Sodium Chloride 0.9% Flush 10 ML (used to flush intravenous (IV) lines) (par level of 100 syringes).

Review of the Omnisupply on the Behavioral Health Unit dated 01/25/19 at 12:30 PM revealed eight medications were not available and on 3 West (Medical Surgical Unit) three medications were not available.

Interviews with RN #7 on 01/24/19 at 3:10 PM, RN #4 on 01/24/19 at 5:20 PM, RN #3 on 01/22/19 at 8:20 PM, RN #2 on 01/24/19 at 1:50 PM, and with RN #11 on 01/29/19 at 6:45 PM revealed they never knew if the facility had physician ordered medications available. The RNs stated when a medication was ordered, they had to "hunt" in every Omnicell in the facility to locate the medication, if they could find the medication at all. The RNs stated "hunting" for medications often caused a delay in treatment.

Interview with Physician #5 on 01/29/19 at 4:30 PM revealed he practiced Internal Medicine at the facility and had for his entire medical career. Physician #5 stated that when the pharmacy notified him of some their inability to obtain medications due to their financial circumstances, he instructed his patients to bring their medications from home. Physician #5 acknowledged this was not the standard of practice for an acute care facility. Continued interview with Physician #5 revealed that he was not aware that the facility did not have Cardizem (a medication used to treat high blood pressure and chest pain). Physician #5 stated that he expected a phone call from the pharmacist telling him that certain medications were not available so he could make an informed decision about how best to proceed with care/prescribing medication.

4. Review of an email from Pharmacist #1 to the Chief Financial Officer (CFO) dated 01/18/19 at 2:03 PM revealed the pharmacist requested a pharmacy order that totaled $22,145.09 and stated "that still isn't enough of some things to last more than a week. When an order hasn't been received for 4 and 5 weeks this is the result-we have to have product to put back on the shelves." At 2:08 PM, on 01/18/19, the CFO responded to Pharmacist #1 that he had given the Chief Executive Officer (CEO)/owner $46,000 to wire to the Pharmacy Distributor.

However, review of an email from Pharmacist #1 to the Pharmacy Distributor's Advisor/Creditor dated 01/24/19 at 1:06 PM, revealed the she needed a narcotic order reinstated and released and needed two retail orders to be released.

However, review of the Pharmacy Distributor's response dated 01/24/19 at 1:55 PM to Pharmacist #1 and to facility staff that included the pharmacist, the Chief Nursing Officer (CNO), and the CFO revealed the vendor would only release the orders if the facility wired $8,378.83 to cover an overdraft (bounced check), plus the cost of the new orders. According to the email, the Pharmacy Distributor would no longer release any more medications to the facility. The email stated, "Please be advised that these will be the last orders we will be able to release. After today, we will be turning over the handling of outstanding amounts to our legal team and will no longer be able to service the account." Further review revealed the CFO forwarded the response to the CEO and copied the CNO and Assistant CNO and stated, "One of the drugs we have on order with [the pharmacy distributor] is one of the drugs the state surveyor has asked if we have in stock. If we can't get this, we are likely to get a J-tag immediate jeopardy."

Review of an email from Pharmacist #1 to the CEO, CFO, and CNO dated 01/25/19 at 8:38 AM revealed the facility's Vasopressin (used in cardiac arrest, shock, etc.) "expires in a couple of crash carts on 01/31/19. We have none in the pharmacy to replace this with. I have asked for this and the Activase to be ordered since 12/10/18. We need the 2nd Activase to be in the hospital to prevent any possible ER diversions due to lack of drug. $13,218.70 (Vasopressin + Activase)." The email further stated, "My narcotic order (from 1/18/19) was deleted due to the payment issues we have. I have no Demerol 25mg/ml in the pharmacy and only 13 vials in the hospital. I have less than 100 tabs of Norco 7.5/325mg in the pharmacy." According to the email, "Verapamil and Epinephrine need to be replaced on the crash carts before 1/31/19. I have none in the pharmacy to replace with...The [retail pharmacy vendor] note must be addressed and all holds off the accounts no later than Tuesday of next week to give me time to get these outdating drugs in and replaced. [Pharmacy Distributor's Advisor/Creditor] has indicated that he is no longer going to communicate with us and is turning the account over to legal. I don't know what this means for getting these and future orders released."

Further review revealed the CEO responded and stated, "So when we paid them $42,000 last week I thought we ordered a bunch of things...After this order how long will things last?" Pharmacist #1 responded with an email on 01/25/18 at 9:56 AM that stated the narcotic order was not released because the money was applied to the facility's debt. The email further stated, "The order did not contain the Activase or the Vasopressin that are needed (The $13K). These were not included on the last order due to the high cost. I wouldn't be sending an order this quick but we need the items that are outdated and narcotic orders...I hope you understand that this is not normal operating procedure for any pharmacy in this country. Pharmacy drug orders are sent daily everywhere else but at this facility and this was how we operated up until finances prevented this. My concern also is that [Pharmacy Distributor] is my only source of several drugs. I can't get them from anywhere else and [the distributor] has again cut us off and frozen the accounts."

Review of the list of medications that Pharmacist #1 requested to be ordered on 01/25/19 at 12:30 PM revealed the following medications were not available at the facility: Acyclovir (antiviral) 5% ointment (par is two 5 gm tubes; Amiloride (used with other meds to treat high blood pressure, swelling due to heart failure or cirrhosis of the liver) HCL 5 mg tablets (par is 100 tablets); Amitriptyline (treats depression) HCL 50 mg tablets (par is 100 tablets); Amoxicillin (antibiotic) 250 mg/5 ml (par is 100 ml); Amoxicillin (antibiotic)/Potclavulanate 62.5 mg/5 ml (par is 75 ml); Azithromycin (antibiotic) 200 mg/5 ml (par is 30 ml); Epoetin Alfa-Epbx (treats low red blood cells) 40,000 U/ml (par is four 1 ml doses); Levofloxacin (antibiotic) 250 mg/50 ml (par is 24 bags), 500 mg/100 ml bags (par is 24 bags), or 750 mg/150 ml (par is 24 bags); or Moxifloxacin (antibiotic) HCL/0.8 % NACL 400 mg/250 ml (par is 12 bags). According to the email, the facility could not obtain Levofloxacin or Moxifloxacin from anywhere but the Pharmacy Distributor and stated, "have to have."

Further review of the list of medications needed by the pharmacist included the following medications that were not available at the facility: Sodium Chloride 0.9% Irrigation (par is 12 1000 ml bags); Meperidine (Brand Name Demerol, pain medication) HCL 25 mg/ml (par is 25); Cyanocobalamin (Vitamin B12) 1000 mcg/ml (par is 25 doses); or Methylprednisolone Acetate (steroid) 40 mg/1 ml (par is 25 doses). According to the email, the facility only had 27 Sodium Bicarbonate (used in emergencies for cardiac arrest and metabolic acidosis) 1 milliequivalent (meq)/ml (par is 10 doses). The email stated the medication was "used on crash carts can't run out."

An interview was attempted with the Advisor/Creditor of the Pharmacy Distributor on 01/29/19 at 12:12 PM. A message was left to return the state agency's call. However, as of the exit date, 01/30/19, the vendor had not returned the state agency's call.

Interview with the Director of Pharmacy on 01/29/19 at 11:00 AM revealed that she had sent an email to the CEO and the Pharmacy Distributor about needed medications, and the distributor referred her to their legal department. According to the Director of Pharmacy, the facility had no ability to obtain any more medications for the facility. She stated that to sign up with another Pharmacy Distributor would take eight (8) weeks or more. The pharmacist stated the CEO's plan to obtain medication since the distributor will no longer supply the facility, was to "borrow" medication from a facility he was attempting to purchase on 02/01/19 in Missouri; however, the pharmacist questioned the legalities of this "scheme."

Interview with a Former Governing Body Member on 01/30/19 at 2:07 PM revealed she was no longer employed by the facility's corporation and no longer functioned as a governing body member as of "last week." The Former Member stated that she had been aware while functioning as a governing body member that the facility was having problems meeting financial obligations including obtaining medications. The Former Member stated that she knew the facility was on a payment plan with the Pharmacy Distributor, but was unaware that the pharmacy had stated they were going to stop supplying the facility with medication. The Former Member stated that communication about the facility was always concerning finances. The Former Member stated she had been aware that if needed supplies could not be obtained because of financial constraints, the CEO would contact the supplier and try to work out a deal. The Former Member stated when she was functioning as a governing body member, she was never informed that the facility was unable to obtain medications needed for patients.

Interview on 01/31/19 at 2:38 PM with the Chief Executive Officer (CEO) and Owner of the facility revealed he was aware of concerns with obtaining medications at the facility. The CEO stated that the facility did have an outstanding balance owed to the Pharmacy Distributor, but stated the facility had paid down the debt considerably. The CEO stated the facility had a financial agreement with the distributor to pay on the outstanding debt while continuing to receive medications. However, the CEO stated that just recently the pharmacy distributor had refused to send medications to the facility and as of 01/24/19, the facility was unable to obtain medication from the pharmacy distributor. The CEO stated this was not the first time the pharmacy distributor had refused to supply medications to the facility, but as soon as a payment was made, they began supplying medications again. The CEO stated he was hopeful that the situation could be "worked out ASAP (as soon as possible)." The CEO went on to state that the corporation owned three other facilities, and if a patient was admitted to the facility and their ordered medication was not in stock, the facility could "hopefully" borrow the medication from a sister facility located in another state (one located approximately 300 miles from the facility and the other located approximately 500 miles from the facility). The CEO stated that he was currently checking to see if "borrowing" medications and "transporting them over state lines" was permitted.

Based on interview, record review, and review of facility policy, it was determined that the facility failed to ensure one (1) of twelve (12) patients (Patient #9) was referred to appropriate agencies for follow-up. On 01/16/19 at 5:30 PM, a social services consultation was requested for Patient #9 because the patient did not have running water at home and did not have transportation to/from appointments or the pharmacy. However, the facility failed to conduct a social services consultation and discharged Patient #9 home on 01/23/19.

The findings include:

Review of the Discharge Planning policy dated August 2018, revealed discharge planning as well as discharge teaching should focus on current needs and anticipated needs based on the reason for hospitalization.

Review of the "Interdepartmental Relationships" policy, approved February 2017, revealed Nursing Services should identify patients who potentially needed a referral to some other agency or nursing facility after discharge, complete documentation as necessary for each referral, and notify Social Services when needs were identified.

Review of Patient #9's medical record revealed the facility admitted the patient on 01/16/19 with diagnoses that included venous stasis disease (slow blood flow in the veins to the legs) with Cellulitis (infection) to both lower extremities. Review of Patient #9's admission assessment revealed the patient had weeping malodorous drainage from both lower extremities and the legs were "red with yellow crusty buildup to calf area bilaterally."

According to the medical record, Patient #9 informed staff his/her condition had worsened because he/she had no running water at home, and had no transportation to get to/from scheduled physician appointments or to/from the pharmacy to get needed medications.

Further review of Patient #9's medical record revealed on 01/16/19 at 5:30 PM a social services consultation was requested. The facility discharged the patient home on 01/23/19, and there was no documented evidence that Adult Protective Services was ever contacted regarding the patient's inability to obtain medical care.

Interview with Registered Nurse (RN) #2 on 01/27/19 at 5:00 PM revealed he discharged Patient #9 home on 01/23/19. He stated he had not reviewed the patient's record at the time of discharge and was unaware that Social Services had not been contacted. RN #2 also stated he was unaware that the patient did not have running water at home, or that he/she had no transportation to get to physician appointments or to obtain physician ordered medications.

Interview with the Assistant Chief Nursing Officer (CNO) on 01/29/19 at 11:00 AM revealed if social services consultations were recommended, the consultation should be completed.

Based on observation, interview, record review, and review of facility policies it was determined the facility failed to provide surgical services consistent with needs and resources and designed to ensure the achievement and maintenance of high standards of medical practice and patient care. Observations and interviews with staff revealed the facility failed to maintain surgical equipment in working order, failed to have formulary medications available for sedation and emergencies, and failed to ensure cleaner/disinfectant used to clean/sanitize surgical instruments and operating rooms was not expired.

The findings include:

Review of the facility policy titled, "Reporting Equipment Failures or Malfunctions," revised January 2018, revealed all known or suspected equipment failures or malfunctions would be reported to the Facility's Management Department. Continued review of the policy revealed if the equipment was needed for the immediate care of a patient, attempts would be made to find an alternate type of equipment, borrow equipment from another facility, or obtain equipment from a rental company or loaner from the equipment supplier. Further review of the policy revealed if the patient was undergoing a procedure, the physician would make the decision to terminate, reschedule, or transfer the patient to another facility.

1. Review of the Operating Room Schedule for Facility #1 dated 01/17/19 revealed Patient #6 was scheduled for a Colonoscopy with Physician #3.

Interview with the Peri-Operative Charge Nurse on 01/22/19 at 4:30 PM revealed in the past surgeries and procedures had to be cancelled due to equipment not being in good repair or working order. The Charge Nurse stated that Physician #3 had to reschedule Patient #6's colonoscopy because the Steris Machine was broken and the facility had no capability to clean the scope used for a colonoscopy. The Charge Nurse stated that due to the facility having an outstanding debt with the vendor, the vendor would not repair the machine until the facility pre-paid for their services.

Interview with Physician #3 on 01/24/19 at 1:50 PM revealed he was the Director of Surgical Services at the facility. Physician #3 stated he was scheduled to perform Patient #6's colonoscopy the day the Steris Machine was "down." Physician #3 stated he was not aware that had the facility had the funds, the machine could have been repaired in enough time to perform the colonoscopy for Patient #6. Physician #3 stated he instructed the facility to have the patient go to another facility where he had privileges and could do the colonoscopy. Continued interview revealed that he was aware of the facility's financial issues, and stated it impeded the ability to provide quality services at times. Physician #3 used the example of the Steris Machine. He stated most facilities would have it repaired prior to procedures being affected. However, at this facility, because of money problems, the vendor will not come unless the facility pays upfront, resulting in a wait time.

Interview with Maintenance Technician #2 on 01/23/19 at 2:00 PM revealed the Steris Machine was "out" last week and could not be repaired because the facility owed the vendor "a lot of money." He stated the vendor was contacted but refused to come without payment in advance. The Maintenance Technician stated he was not qualified to repair the machine.

Review of the medical record for Patient #6 from Facility #3 revealed Facility #3 admitted Patient #6 on 01/17/19 with a complaint of rectal bleeding. Physician #3 performed a Colonoscopy on Patient #6 without issue and the patient was discharged home the same day.

2. Observation of medications available in the Surgery Department on 01/23/19 at 10:15 AM revealed the following medications were not available: Lidocaine (local anesthetic) 1%, 30 milliliter (ml) vials (par was for 8 vials); Diprivan (short acting sedative used during surgical procedures; also used to sedate patients mechanically ventilated) 10 milligrams/milliliter (mg/ml), 50 ml vial (par was 35 vials); Diprivan 10 mg/ml, 100 ml vial (par was 20 vials); Ampicillin (antibiotic) 2 gm vial (par is 2); Atropine Sulfate (emergency drug for no or low heart rate) 1 mg/ml, 1 ml vial (par is 4); Bupivacaine/Epi .25% (local anesthetic) 30 ml vial (par is 10); Ancef (antibiotic) 1 gm, (par is 6): Gentamicin (antibiotic) 80 mg/50 ml IV (intravenous) (par is 4); or Isovue (contrast used in CT scans) 300 (50 ml vial) (par is 6). In addition, the facility surgery department only had eight vials of Lidocaine 1% 10 mg/ml vial (par was 28 vials).

Interview with Registered Nurse (RN) #13 on 01/30/19 at 1:50 PM revealed staff had to leave the Operating Room at times to obtain needed supplies to continue surgeries. Continued interview with RN #13 revealed the facility also had to cancel surgeries due to malfunctioning equipment or not having the appropriate supplies on hand.

Interview with Certified Registered Nurse Anesthetist (CRNA) #1 on 01/30/19 at 3:00 PM revealed the facility did not have the medications she preferred to use when anesthetizing patients. She stated the last time she was at the facility approximately one month ago, the facility had "a big vial" of Diprivan, which was "wasteful" as most of the medication had to be thrown away because it was not used on the patient.

Interview with the Chief Financial Officer (CFO) on 01/28/19 at 6:00 PM revealed he managed the facility's finances and was in contact with the Chief Executive Officer frequently regarding the financial situation of the facility. The CFO stated the Pharmacy Distributor would no longer provide medications to the facility due to an outstanding debt of $500,000 and would only speak to the facility through the distributor's attorney. According to the CFO, the facility had no plans on paying the Pharmacy Distributor and it would take approximately eight (8) weeks to obtain another Pharmacy Vendor. The CFO stated the CEO's plan was to attempt to borrow medication from a "sister" facility that the CEO was attempting to purchase in Missouri.

3. Observation during tour on 01/23/19 at 10:50 AM of the sterile processing area revealed three (3) bottles of the Virex TB (an all-purpose, hospital-grade cleaner, sanitizer, and disinfectant) available for use for cleaning surgical instruments prior to being sterilized. Two (2) bottles expired on 05/14/18 and one bottle expired on 08/10/18. Further observation of three (3) Virex TB bottles in storage revealed they also expired on 05/14/18.

Observation in central supply on 01/23/19 at 10:55 PM revealed fourteen (14) bottles of Envy Disinfectant Cleaner with an expiration date of 06/14/18.

Interview with the manufacturer of Virex TB and Envy on 01/23/19 at 11:35 AM revealed the date that was stamped on the bottles was the expiration date of the product. The manufacturer stated it was not recommended to be used in a health care setting past the expiration date.

Interviews with Sterile Processing Technician #1 on 01/23/19 at 10:55 AM and with Sterile Processing Technician #2 on 01/23/19 at 11:00 AM revealed they were unaware the Virex TB bottles were expired. Continued interviews revealed they had to "hide" cleaner from the rest of the facility in order to keep from running out. The technicians stated they thought the Virex TB solution came from a facility in another state that had closed. Further interviews revealed the technicians ran out of biological indicators (an indicator is placed in each item to be sterilized and it provides information on whether necessary conditions were met to provide a level of confidence in the process) in December 2018 and were not able to sterilize any instruments for approximately a week. The technicians stated they were fearful it would happen again.

Interview with the Director of Housekeeping on 01/23/19 at 11:10 AM revealed Virex TB and Envy cleaners were also used to disinfect the Operating Room, Emergency Department, and all patient care areas. The Director was unaware the cleaner was expired.

Interview with the Chief Nursing Officer (CNO) on 01/23/19 at 2:30 PM revealed at times the facility orders supplies but the supplies were shipped to another state, to another facility owned by the CEO (Chief Executive Officer). Continued interview revealed the CEO had also instructed staff to obtain supplies from a facility in another state that had "been closed for a while." The CNO stated the disinfectants probably came from that facility and that is why they were expired.

Interview with Physician #9 on 01/30/19 at 11:00 AM revealed he left Southeastern KY Medical Center in October 2018 because he felt continuing to provide care in the facility was "endangering the lives of my patients" because there was not adequate equipment or supplies in the facility. He stated he had scheduled two patients for laparoscopic cholecystectomies (removal of the gall bladder) in "mid October" but was notified that the facility was unable to sterilize instruments. He stated he had to call the call the patients and tell them that he was unable to do their surgery as scheduled. Further interview with Physician #9 revealed availability of supplies was also a concern at the facility. He stated that there had been times during surgical procedures when staff had to leave the Operating Room to go search the hospital for sterile gauze or tape because the facility was unable to keep the rooms adequately stocked. Physician #9 also stated medication availability was a concern. He stated he was constantly forced to change antibiotic orders because they were not available, which caused a delay in patient's antibiotic treatment. Physician #9 stated he had a patient who presented to the ED with a "completely blocked colon," which required emergency surgery, and a critically low white blood count (WBC) of 0.8. He stated that without his knowledge, the hospital had stopped stocking the medication the patient needed to "stimulate the bone marrow" to produce more blood cells. He stated "they had to go searching to area hospitals until they were able to obtain the needed medication, which wasn't provided to the patient until late in the night." According to Physician #9, he was "unsure how a surgical department was functioning without propofol [Diprivan]" because the medication was frequently used in the surgical setting.

Based on interviews, record reviews, review of a facility policy, and review of a facility investigation, it was determined the facility failed to execute an informed consent for one (1) of twelve (12) sampled patients (Patient #1) prior to a procedure in the surgery department.

On 08/16/18, Patient #1 was admitted for abdominal pain and signed a consent to have an Esophagogastroduodenoscopy (EGD) (a procedure to examine the stomach and upper portion of the small intestine). However, review of the "Operating Room Nurses Note" and a facility investigation revealed the facility attempted to perform a colonoscopy (a procedure to examine the colon from the rectum) and performed a sigmoidoscopy (examined the inner part of the rectum and lower colon) without the patient's consent.

The findings include:

Review of the facility policy titled, "Verification of Correct Site, Correct Procedure and Correct Patient for Invasive or Surgical Procedures," approved June 2017, revealed the facility must complete the following steps before every invasive or surgical procedure: confirmation of the correct procedure and patient shall occur in pre-procedure/pre-operative area, involving the patient whenever possible and completing a "time out" for all cases. Continued review of the policy revealed time outs would be performed before all surgical or invasive procedures. Further review of the policy revealed the facility defined a "time out" as the pause in patient care activity conducted by the surgical team immediately before starting the procedure to conduct a final assessment that the correct patient, site, positioning, and procedure are identified and that all relevant documents, related information, and necessary equipment are available. According to the policy, time outs will cause all other activities to be suspended; will be initiated by a designated Registered Nurse circulator; will involve all members of the surgical team; and will address the correct patient, correct side/site marked, consent form present and accurate; agreement on the procedure to be done; correct patient position; and reconcile problems if the responses among team members differ.

Review of Patient #1's medical record revealed the facility admitted the patient on 08/16/18. Review of Patient #1's History and Physical (H&P) dated 08/15/18 and updated on 08/16/18 at 12:00 PM, revealed Patient #1's chief complaint was "[Shortness of Breath], Hepatitis C, Vomiting and Abdominal Pain," There was no documented Impression/Diagnosis or plan.

Review of the "pre-admission order sheet" dated 08/16/18 revealed Patient #1 was diagnosed with Abdominal Pain and the pre-surgical orders were: Pre-op medications as instructed by the surgeon's office and prep as indicated for colonoscopy. However, review of an Informed Consent form revealed Patient #1 consented for an EGD on 08/16/18 at 11:55 AM, not a colonoscopy. In addition, Physician #1 signed the informed consent form for an EGD on 08/16/18 at 12:00 PM.

Review of Patient #1's "Pre Anesthesia Assessment," dated 08/16/18 at 12:16 PM revealed the "proposed procedure" was an EGD. Review of the "Anesthesia Record," dated 08/16/18, also revealed the patient was having an EGD. According to the Anesthesia Record, anesthesia was initiated for Patient #1 on 08/16/18 at 12:56 PM for an EGD and a "Time Out" was conducted at 12:57 PM. The record revealed anesthesia was stopped at 1:04 PM and the patient was taken to the Post-Anesthesia Care Unit (PACU).

Review of the Comprehensive Surgical Checklist dated 08/16/18 for Patient #1 revealed staff documented that the RN confirmed with the patient the patient's identity, the procedure, and the consent. Staff also documented a time out was conducted and confirmation of the patient's identity, procedure, and consent was conducted.

Review of the "Operating Room Nurses Note" dated 08/16/18 also stated Patient #1 was identified by name, birthdate, chart, and operative consent. However, continued review of the note revealed Patient #1 was taken in the OR room at 12:56 PM and an "Active Time Out" was conducted at 12:57 PM and the procedure "Flexible Sigmoidoscopy" was verified, not an EGD, the only procedure to which the patient consented.

Review of a facility "Variance Report Investigation" dated 08/16/18 revealed Patient #1 was taken into the Operating Room and a colonoscopy was attempted. Due to "poor prep," a flex sigmoidoscopy was done and Patient #1 was transported to PACU. The Investigation stated that Physician #1 spoke with Patient #1's family member and informed them the patient had a "poor prep." The family informed Physician #1 that the patient was scheduled for an EGD, not a colonoscopy. According to the investigation, Physician #1 brought the patient's record to staff who reviewed the patient's medical record and upon review of the surgical consent, history and physical, and physician orders, it was determined the attempted colonoscopy was "performed in error." According to the investigation, the RN "believes" he initiated the time out procedure and stated the procedure was supposed to be an EGD; however, the room had been set up with equipment for a colonoscopy and "with no objections from any team members an attempted colonoscopy was performed." The investigation revealed the OR technician stated that the time out was conducted; however, staff stated the patient was supposed to have a colonoscopy. The CRNA initially stated the RN conducted the time out and stated the procedure was supposed to be a colonoscopy, then the CRNA changed her mind and said it was supposed to be an EGD. Further review of the investigation revealed all staff involved stated a "time out" was conducted, but they made conflicting statements about which procedure was announced. Further review revealed the OR room was set up for a colonoscopy. The investigation stated Patient #1 was then taken back to the OR suite and an EGD was performed without incident.

Interview with Peri-Operative Charge Nurse on 01/24/19 at 3:55 PM revealed she was notified of the incident with Patient #1 on 08/16/18. She stated she notified Administration and began an immediate investigation. The Charge Nurse stated that the OR room was prepped for a colonoscopy, not for an EGD. She further stated that she interviewed the circulating nurse, the two surgery technicians (CST) that were present in the OR, and the Certified Registered Nurse Anesthetist (CRNA), who stated a "time out" was conducted. The Circulating Nurse and CRNA stated they announced an EGD; however, neither stopped Physician #1 from performing the colonoscopy. According to the Charge Nurse, she re-educated staff regarding the time out process; however, Physician #1 refused to discuss the incident and the Director of Surgery refused to re-educate Physician #1. Further interview revealed that Physician #1 continued to perform procedures at the facility until he left in December 2018.

Interviews were attempted with Physician #1 and the Director of Surgical Services; however, both were unable to be reached and no longer worked for the facility.

Based on observation, interview, and record review, it was determined the facility failed to ensure the Emergency Department was integrated with other departments of the facility to ensure the facility could immediately make available the full extent of its patient care resources to assess and render appropriate care for emergency patients.

Patient #12 presented to the Emergency Department (ED) on 12/04/18, in full cardiac arrest. On two different occasions, Patient #12 required multiple doses of Epinephrine (a medication to stimulate the heart) in an effort to sustain the patient's life. However, the facility failed to have enough medication to treat the patient, and medication had to be supplied to the facility by the Emergency Medical Services (EMS) that had transported the patient to the ED.

On 07/17/18, EMS was attempting to transfer a patient to the ED who was exhibiting signs and symptoms of an acute stroke. However, when EMS contacted the ED to inform them that they were en route with the patient, they were informed by RN #11 not to bring the patient to the ED because they would "kill this guy." Subsequently, EMS contacted a transport helicopter and the patient was flown to another facility. Interviews with staff revealed the facility failed to have medication available used to treat patients who were having a stroke.

Tours of the Emergency Department (ED) on 01/23/19 and 01/30/19 revealed the facility did not have a functioning telemetry monitor (shows the electrical activity of the heart) located at the nursing station, and staff were unable to monitor a patient's cardiac status unless they were present in the patient's room. Further observations revealed eight (8) of nine (9) rooms in the ED did not have a functional pulse oximeter (a device used to measures the amount of oxygen in the blood). Observations in the ED also revealed none of the nine (9) ED rooms contained a functional biohazard "sharps" container. There were only two (2) biohazard "sharps" containers located in the ED, one container was located in the hallway and another in the physician's charting room. Observations on 01/30/19 revealed ED staff had to transport used needles and devices through the hallway to get to a biohazard container to dispose of the items. In addition, observation of the casting room on 01/23/19 at 9:45 AM revealed it contained a limited number of supplies necessary to cast fractured bones of patients presenting to the ED in need of casting services. The ED's entire supply of casting tape was expired and the appropriate sizes were not available to treat various injuries.

The findings include:

Review of the facility policy titled, "Procedure List for ED," revised January 2019, revealed the facility would provide services including treatment for cardiac and/or respiratory arrest; cardiac monitoring and treatment of arrhythmias; treatment of patients in respiratory distress; treatment for acute stroke, including the administration of thrombolytics (medications to dissolve blood clots); treatment of various fractures; treatment of trauma patients; hypertensive crisis; anaphylactic shock; disaster triage; treatment of acute myocardial infarctions (heart attack) including the administration of thrombolytics; and pediatric emergencies.

Review of the facility's policy, "Radiology Scope of Service," approved February 2017, revealed the Radiology Department was a medical specialty that employed the use of an array of imaging technologies to diagnose or treat patient conditions. The policy stated that after normal business hours, a technologist would be "on call" and responsible for all services provided in the facility.

The policy stated "after hours" the "on call" technologist was to be contacted by the hospital nursing staff for any and all emergencies that required their services. The policy also stated that the "on call" technologist would respond to the facility within forty-five (45) minutes of being contacted by facility staff.

1. Review of Patient #12's medical record revealed the patient arrived at the facility's ED on 12/04/18 at 8:02 PM. The record stated that report received from EMS, who had transported the patient to the facility, revealed the patient had attempted suicide, was unresponsive, and in full cardiac arrest (unconscious with no heart function or breathing) with cardio pulmonary resuscitation (CPR) in progress upon arrival. Patient #12 had also been intubated (a tube placed in the windpipe so oxygen could be delivered to the lungs) by EMS en route to the facility.

Continued review of Patient #12's medical record revealed that upon arrival to the facility Patient #12 was assessed to have a weak carotid pulse and lifesaving measures continued. Patient #12 was administered twenty-two (22) ampules of Epinephrine from 8:08 PM until 8:55 PM, at which time it was determined that Patient #12 had a palpable pulse, and at 8:58 PM the patient was placed on a mechanical ventilator (a machine that assists a patient to breathe). Review of physician orders for Patient #12 dated 12/04/18 at 9:10 PM, revealed the ED physician ordered Patient #12 to have a chest x-ray obtained "STAT" (immediately). However, review of Patient #12's medical record revealed no evidence the chest x-ray was obtained as ordered.

On 12/04/18 at 9:35 PM Patient #12 again went into cardiac arrest, and CPR was resumed, and eight (8) additional ampules of Epinephrine were administered to the patient between 9:35 PM and 9:55 PM, at which time Patient #12 was pronounced deceased.

Interview with RN #13 on 01/30/19 at 2:30 PM revealed she was working when Patient #12 was treated in the ED. The RN stated that she could not state emphatically why Patient #12 did not get the chest x-ray as ordered, but stated there was no one from the Radiology Department present in the facility while Patient #12 was receiving treatment. The RN also stated that the facility ran out of epinephrine in the ED while treating Patient #12. RN #13 stated supplies in the ED had been a problem for "some time." The RN stated that EMS had to provide epinephrine to the facility while Patient #12 was being treated, but was unable to say exactly how many ampules were "borrowed" from EMS.

Interview with Paramedic #1 on 01/29/19 at 2:45 PM and with Emergency Medical Technician (EMT) #2 on 01/29/19 at 3:00 PM revealed they were the EMS personnel who transported Patient #12 to the ED on 12/04/18 and remained in the ED assisting facility personnel until Patient #12 was pronounced deceased. Paramedic #1 and EMT #2 stated that the ED staff never performed a chest x-ray on Patient #12. Continued interview with Paramedic #1 revealed that when they took Patient #12 into the ED, they also took their medication box into the facility. Paramedic #1 stated that they routinely take their medication box into this facility with them, because it is routine for the ED not to have the medication needed, and they often supply it to the facility. Further interview confirmed that the facility ran out of Epinephrine medication while treating Patient #12 and they used several ampules from their medication supply. Although Paramedic #1 and EMT #2 were unable to recall exactly how many ampules of Epinephrine were supplied to the facility, they stated they had supplied "the majority" of Epinephrine administered to Patient #12. EMT #1 stated the facility's ED was the only one he had ever had to supply with medications or equipment during his entire career.

Interview with the Director of Pharmacy on 01/29/19 at 11:00 AM revealed that as of 01/29/19, she was filling the facility's crash carts (carts utilized for the transportation and dispensing of emergency medication used in a lifesaving situation) with the last of the facility's "emergency medications" including Epinephrine, and she did not have the ability to obtain any more due to the facility's financial situation.

Observation of the facility's ED on 01/30/19 at 5:00 PM revealed the ED had four (4) ampules of Epinephrine that could be administered to an adult patient and four (4) ampules of Epinephrine that could be administered to a pediatric patient. However, all eight ampules of Epinephrine had expiration dates of 01/31/19.

2. Review of an audio recording of an Emergency Medical Services (EMS) dispatch call recorded on 07/17/18, between the facility's ED and EMS Dispatch revealed the dispatch station called the ED on 07/17/18, exact time unknown, to communicate to the ED that EMS was en route to their facility with a patient who was believed to be having an acute stroke. RN #11 is heard answering the phone call and confirming that it was the ED. The dispatcher proceeds to tell the nurse that EMS was en route to the facility with a patient who appears to be having an acute stroke. The Nurse then states, "If this is a stroke symptom it needs to be flown, I mean we are just going to kill this guy, you know what I'm saying. Just tell them it is critical that he gets treatment immediately." The dispatcher is then heard communicating with the EMS crew who was transporting the patient, and then stating to RN #11, "Okay, I'll call the helicopter." The nurse then replies, "thank you, dear," and the call ends.

Interview with the EMS Director on 01/29/19 at 2:45 PM revealed he was the paramedic on the call when RN #11 instructed EMS not to bring the stroke patient to the ED. The EMS Director stated that at that time the ambulance transporting the patient was approximately sixteen (16) minutes from the facility. The Director went on to state that the helipad used for the helicopter to land and pick up the stroke patient was the helipad utilized by the facility and was located directly across the street from the facility. The Director stated that after EMS arrived at the helipad with the patient they waited another sixteen minutes for the helicopter to arrive to transport the patient. In addition, according to the EMS Director the flight from the facility's helipad to the receiving hospital located seventy-three (73) miles away was approximately thirty (30) minutes long. Further interview with the EMS Director revealed that EMS staff had since been informed by the facility nursing staff that the facility did not have any Tissue Plasminogen Activator (tPA) (a medication administered to dissolve blood clots); subsequently, the EMS Director stated any patient believed to be having an acute stroke would be transported to another acute care facility, despite the location or time of travel to the alternative facility.

Interview with RN #11 on 01/29/19 at 6:45 PM revealed that she was working in the ED when Dispatch called the facility informing them of the incoming stroke patient. RN #11 stated the ED physician working that night was the staff member who initiated the conversation with her to instruct EMS to "fly the patient out" instead of treating the patient in the ED. The RN stated the ED physician and she discussed the fact that the facility did not have radiology services in the facility from midnight until 7:00 AM, and a Computerized Tomography (CT) technician would have to be "called in," and then it would take an hour for the results to be available, and by that time, the patient "would be dead." Continued interview with RN #11 revealed working in the facility's ED was like working in a "low rent doctor's office." RN #11 stated that the most basic of laboratory studies were sent out to be processed and nursing staff had to search all over the building for medication, and then it may or may not be found. The RN stated the ED did not have even the "basic supplies."

Interview with the Director of Pharmacy (DOP) on 01/23/19 at 2:45 PM revealed the facility had only one (1) dose of tPA medication available in the facility. The DOP stated that due to the cost of the medication she could not obtain any more. The DOP stated that the facility was in debt to the pharmacy supplier for approximately one-half million dollars, and they could not obtain any medications without paying "up front" for them. She further indicated tPA medication cost approximately ten thousand dollars and the facility did not have funds available to purchase the medication.

3. Tours of the Emergency Department (ED) on 01/23/19 at 9:45 AM and on 01/30/19 at 5:15 PM, revealed the facility had nine (9) ED rooms, two (2) of the rooms were dedicated for trauma services and one (1) of the rooms was dedicated for casting services. Continued observations on 01/30/19 at 5:15 PM revealed a telemetry monitor was located at the nursing station; however, the monitor was not operational and could not be utilized to monitor patients who had presented to the ED with suspected cardiac problems or patients who were experiencing an acute myocardial infarction (heart attack).

Interviews on 01/30/19, at 5:20 PM with Registered Nurse (RN) #9, at 5:45 PM with RN #10, and at 2:30 PM with RN #13 revealed the telemetry monitor at the nursing station had not worked for "months." RN #13 stated there had been occasions when two or three patients were present in the ED who required cardiac monitoring; however, the only way to continuously monitor the patient's cardiac status was to stay in the room with the patient and observe the bedside monitor. All the staff interviewed stated it was impossible to stay in the room with each patient in the ED, and at times this had presented situations that placed the patients at risk for critical changes in their condition not being recognized timely and acted on immediately.

Further review of the ED rooms revealed eight (8) of the nine (9) rooms did not have a working pulse oximeter.

Further interviews on 01/30/19, at 5:20 PM with Registered Nurse (RN) #9, at 5:45 PM with RN #10, and at 2:30 PM with RN #13, revealed only one room in the ED was equipped to provide continuous pulse oximetry monitoring for a patient. The nurses stated that there were two (2) "portable stations" that they utilize for obtaining patient vital signs, which also contained disposable pulse oximetry equipment that was to be used on one patient and then discarded. However, the nurses stated that due to a lack of supplies in the ED and not having any additional disposable pulse oximeter sensors available, the staff utilized the same disposable senor for every patient in the ED. The staff were unable to say how long the sensors had not been available, but stated, "a while."

Continued observations of the ED revealed none of the nine (9) ED rooms contained a functional biohazard "sharps" container. The only biohazard "sharps" containers located in the ED were in the hallway and in the physician's charting room. Observations on 01/30/19 revealed ED staff had to transport used needles and devices through the hallway to get to a biohazard container to dispose of the items, creating a substantial risk of exposure of a bloodborne illness or injury to patients, staff, and visitors in the ED.

Continued interviews on 01/30/19, at 5:20 PM with Registered Nurse (RN) #9, at 5:45 PM with RN #10, and at 2:30 PM with RN #13 revealed the "sharps containers" in the rooms had not been functional for "a while." The staff stated they had to utilize the large sharps container in the hallway or the one in the physician's room. The staff interviewed stated they recognized this practice to be a "serious" problem related to infection control.

4. Observation of the casting room on 01/23/19 at 9:45 AM revealed it contained three (3) rolls of 1-inch casting tape each of which had an expiration date of October 2015; nine (9) rolls of 2-inch casting tape each of which had an expiration date of December 2018; one (1) roll of 2.5-inch casting tape with an expiration date of October 2015; and one 6-inch roll of casting tape with no expiration date present. Further review of the casting supplies revealed sixteen (16) casting sponges were present, one (1) with an expiration date of March 2017, seven (7) with an expiration date of June 2017, two (2) with an expiration date of October 2015, and six (6) with an expiration date of December 2015.

Interview with the Casting Technician on 01/23/19 at 10:00 AM revealed he was aware that the casting supplies had expired but stated they were the only supplies available. The Casting Technician stated that the one (1) roll of 6-inch casting tape, which was used for large areas such as legs, is an item that is frequently used, because a fractured leg is a common injury seen in the ED. Continued interview with the casting technician revealed that due to the casting supplies "being so old" and out of date, it was difficult at times to make the castings stick or they had to "make do" utilizing inappropriately sized tape to try and make a cast that would fit, because the appropriate size casting tape was not available.

Interviews on 01/30/19 at 6:15 PM with the Chief Nursing Officer (CNO) and the Assistant Chief Nursing Officer (ACNO) revealed they denied having any knowledge of the facility having to "borrow" medications and supplies from EMS to operate the ED. However, continued interview with the CNO and ACNO revealed that the EMS Director had requested to meet with them "sometime in the summer" of 2018, because of concerns he had with the facility's ED. The CNO and ACNO stated during the meeting they were informed by the Director of the phone call that had transpired between the ED and EMS Dispatch. The CNO and ACNO stated an investigation was initiated and they spoke with RN #11 and the physician who was working in the ED. According to the NCO and ANCO it was determined by RN #11 and the ED physician that due to the facility not providing neurological services, it would be better for the patient to be flown to another facility, and no changes were made in the ED as a result of the investigation. Continued interview with the CNO and ACNO revealed they were aware that the telemetry monitor was not working in the ED and they had made the Chief Executive Officer (CEO) and the Chief Financial Officer (CFO) aware; however, no action had been taken and the ED continued to not have a functioning cardiac monitor at the nurses' station. Continued interviews revealed the CNO and the ACNO were not aware of the lack of pulse oximetry sensors not being available in the ED. The CNO and ACNO also stated the facility had been out of biohazard sharps containers for the ED rooms for "months." The CNO and ACNO stated that decisions on which supplies were obtained were made on a day-to-day basis and they try to obtain the most critical supplies first, but due to the financial condition of the facility, not all needed supplies could be made available.

Based on interview, record review, review of facility policies/procedures, and review of the American Heart Association/American Stroke Association Guidelines, it was determined the facility failed to ensure the policies and procedures governing medical care provided in the Emergency Department were established and evaluated on an ongoing basis. The facility had an "Acute Stroke Practice Standard for the Emergency Department" in place with specific criteria and interventions for the medical staff to follow and implement when a patient presented to the Emergency Department (ED) with signs/symptoms of a stroke. However, the facility failed to implement the standard of care on 11/12/18 at 10:35 AM, when Patient #10 presented to the ED with a "significantly elevated blood pressure" and exhibiting signs and symptoms of a stroke. The facility failed to implement their Acute Stroke Practice Standard for the Emergency Department; subsequently, Patient #10 did not receive medical imaging including a non-contrast head computed tomography (CT) scan until after being admitted to the medical surgical floor and five (5) hours after arrival to the ED. In addition, the facility failed to administer Patient #10 the stroke scale assessment screening to determine the extent of deficits being experienced by the patient. On 11/12/18 at 4:20 PM the results of a CT scan of the head for Patient #10 revealed the patient was experiencing an apparent evolving infarct in the right parietal area. The patient was transferred to Facility #6 on 11/12/18 at 8:15 PM for treatment of an acute stroke.

The findings include:

Review of the facility's policy, Acute Stroke Practice Standard for the Emergency Department (ED), undated, revealed when a patient presented to the Emergency Department with a suspected acute stroke, the use of a stroke severity scale was recommended. In addition patients exhibiting signs and symptoms of a stroke should receive imaging including a non-contrast head computed tomography (CT) scan. The policy further stated that imaging should occur within twenty (20) minutes of arrival in the ED. The policy further stated that imaging should occur within twenty (20) minutes of arrival in the ED.

Further review of the facility's Acute Stroke Practice Standard for the Emergency Department revealed a National Institute of Health (NIH) Stroke Scale was to be utilized when a patient presented with signs/symptoms of a stroke for the healthcare provider to objectively quantify any possible impairment caused by the stroke.

Review of the American Heart Association/American Stroke Association Guidelines revealed time was critical when experiencing a CVA and immediate treatment could minimize the long-term effects of a stroke and/or even prevent death. The guidelines listed numbness and weakness especially affecting one side of the body, slurred speech, and confusion as classic warning signs of a stroke. In addition the guidelines classified a hypertensive crisis as a severe increase in blood pressure that could lead to a stroke. The guidelines also stated that a systolic (top number) of 180 millimeters of mercury (mm Hg) or higher or a diastolic (bottom number) of 120 mm Hg or higher can damage blood vessels.

Review of Patient #10's Emergency Department medical record revealed the patient presented to the ED on 11/12/18 at 10:35 AM, with severe hypertension (an increased blood pressure), left sided facial and arm heaviness and swelling of the left side of the tongue. In addition review of a History and Physical for Patient #10 dated 11/12/18, revealed Patient #10 also was exhibiting slurred speech and was characterized by familiar health care providers as not acting normally. The patient was also assessed to have a family history significant for stroke.

Further review of the medical record revealed Patient #10 was administered Clonidine 0.2 mg (a medication to lower blood pressure) by mouth at 11:01 AM and the patient's blood pressure was recorded as 240/140 (normal 120/80) at 11:08 AM. The patient was triaged as "urgent." However, there was no evidence found to indicate the facility initiated their own Stroke protocol by conducted imaging of Resident #10 including a non-contrast head (CT) scan within twenty (20) minutes of arriving to the ED or administered the stroke scale assessment as required.

Continued review of Patient #10's Emergency Department medical record revealed the patient's blood pressure was recorded as 252/146 at 11:27 AM and at 11:34 AM the patient was administered Metoprolol 5 mg (a medication to lower blood pressure) via Intravenous (IV) access. At 11:42 AM Patient #10's blood pressure was recorded as 238/142 and at 11:45 AM the patient was again administered Metoprolol 5 mg via Intravenous (IV) access. At 12:20 PM the patient's blood pressure was recorded as 230/142 and the patient at that time was administered Hydralazine (a medication to lower blood pressure) 20 mg via IV. At 12:35 PM Patient #10's blood pressure was recorded as 183/120. At 2:22 PM the patient's blood pressure was recorded as 201/134 and at 2:56 PM the patient was administered Labetalol (a medication to lower blood pressure) 5 mg via IV. Further review of the patient's medical record revealed at 3:15 PM the decision was made to admit the patient to the medical surgical floor for management of hypertensive crisis, despite Patient #10 not receiving medical imaging including a non-contrast head (CT) scan within 20 minutes of arriving to the ED or being administered the stroke scale assessment as required by the facility's policies and procedures.

Further review of Patient #10's medical record revealed the patient arrived at the medical surgical unit on 11/12/18 at 3:30 PM, and at 3:41 PM the patient's blood pressure was documented as 180/108. At 3:47 PM, the admitting physician documented that a CT scan of the head would be obtained "just to be on the safe side."

Review of a Radiology Imaging Department Report for Patient #10 dated 11/12/18, revealed a CT of the head was obtained on the patient at 3:42 PM and the documented reason for the scan was "numbness of side head and tongue." Further review of the report revealed the findings of the head CT was "an apparent evolving infarct in right parietal area."

Continued review of Patient #10's medical record revealed at 4:48 PM the results of Patient #10's CT of the head was called to the admitting physician. Subsequently, at 6:15 PM, Patient #10 was transferred to Facility #6 for treatment of an acute stroke.

Interview with RN #8 on 01/28/19 at 6:00 PM, reveled she was working in the ED on 11/12/18, when Patient #10 presented to the facility. RN #4 stated that the she was unaware why a CT scan of the head was not ordered for Patient #10 in the ED. The RN stated that the physician was aware that the patient's blood pressure was elevated. RN #4 stated she did not perform the NIH stroke scale assessment on Patient #10 because to the best of her recollection the patient was not exhibiting slurred speech or having any neurological deficits that she could recall, despite contrary documentation in Patient #10's medical record.

Interview with Registered Nurse (RN) #4 on 01/29/19 at 12:45 PM revealed she provided care to Patient #10 after being admitted to the medical surgical floor. RN #4 stated she was familiar with the patient because he/she was employed at the facility. She stated the patient was "thick tongued" and the patient's speech was not normal. RN #4 stated the patient "wasn't acting right" and Patient #10's blood pressure continued to be elevated even after being administered "a large amount of medications." The RN stated after she evaluated Patient #10, she identified that a CT scan had not been performed in the ED which was routine protocol for the facility. RN #4 stated this was concerning "especially since we were familiar with (him/her) and something wasn't right." She stated she contacted the physician and orders were obtained for a CT scan. RN #4 stated the CT scan confirmed the patient was having a stroke so an "immediate transfer" was arranged.

Interview with Physician #5 on 01/29/19 at 4:30 PM revealed Patient #10 presented to the ED with swelling of the tongue, slurred speech, and high blood pressure. Physician #5 stated he felt that Patient #10 was "clinically stable" other than the patient's high blood pressure. Physician #5 stated when he examined Patient #10 the patient had already been admitted to the floor, after being "stabilized" in the ED. Physician #5 stated he was informed by nursing staff that the patient did not appear "normal," and a CT scan was ordered. Continued interview with Physician #5 revealed that as soon as the CT scan indicated Patient #10 was having a stroke, he immediately transferred Patient #10 to Facility #6.

Interview with the Chief of Staff (COS) on 01/28/19 at 5:00 PM revealed the NIH stroke scale assessment screening should have been administered to Patient #10 and a CT scan of the head obtained immediately upon the patient presenting to the ED. The COS also stated that Patient #10 should have never been admitted to the medical surgical floor in a hypertensive crisis due to the lack of staff to care for a critically ill patient, the facility not having adequate supplies, nor the capability to provide the level of care that Patient #10 required. Continued interview revealed the facility did not have a Cardiologist or Neurologist on staff to consult regarding these types of patients.