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Based on review of the surgical schedules, and employee interviews, it has been determined that the hospital failed to have a Governing Body that is effective in carrying out its responsibilities for the conduct of the hospital.

Findings are as follows:

During an investigation of a complaint relative to cancellation of surgical procedures due to non-payment of vendors, the following was identified:

According to the CMS Regulations and Interpretive Guidelines for Hospitals, under section §482.12 Condition of Participation: Governing Body states: "...There must be an effective governing body that is legally responsible for the conduct of the hospital..."

Review of surgical schedules and procedure bookings for October 2023, revealed several endoscopic and surgical procedures that were cancelled related to the hospitals inability to pay for the medical supplies necessary to complete the procedures.

Surveyor review of the Governing Body minutes from 2/9/2023, 9/25/2023 and 10/23/203, failed to identify that supplies and equipment vendors on credit holds were reported to the board. These minutes failed to provide evidence that the Governing Body was apprised of the hospitals failure to order supplies to complete scheduled elective surgical procedures resulting in multiple cancellations.

The 9/25/2023 minutes state under the section "2022 Supply Chain Strategic Overview": states in part 2022-2023 "significant credit holds: limited impact on operations". The minutes fail to include information relative to the hospital borrowing supplies and equipment from other facilities to perform certain procedures and surgeries. The 10/23/2023 meeting minutes fail to include any information relative to the supply chain vendors on credit holds and or procedures being cancelled.

On 11/1//2023 at 11:30 AM, during a meeting with the Chief Executive Officer (CEO), he stated he was unaware of the recent cancellations, and was unable to provide evidence that the Governing Body held meetings to discuss the hospitals inability to order the necessary supplies to complete several surgical procedures resulting in their cancellation.

During an interview with the Operating Room Director and the Administrator of Surgical Services on 10/31/2023 at approximately 11:15 AM, they acknowledged that the hospital had cancelled 2 orthopedic surgical procedures, 2 endoscopy procedures, and failed to book 2 endoscopy procedures due to the lack of supplies and equipment necessary for the surgery.

(Refer to A-049 and A-057)

Based on record review and staff interviews, it has been determined that the medical staff which is accountable to the governing body failed to ensure quality of care to all patients relative to the cancellation of 6 scheduled surgical procedures, patient's ID # 1, 2, 3, 4, 5 and 6.

Findings are as follows:

During a complaint investigation, it was determined that the hospital failed ensure that it has the necessary equipment to safely perform the following surgical procedures.

A Review of the October 19, 2023, surgery booking office forms and "cancel Procedure records" revealed that the following orthopedic procedures were cancelled.

1. Patient ID # 1 was scheduled for left knee surgery on 10/19/2023 and was notified that the surgery was cancelled.

2. Patient ID # 2 was scheduled for left knee surgery on 10/19/2023 and was notified that the surgery was cancelled.

During an interview with the Orthopedic Surgeon, Staff F, on 10/26/2023 at 3:15 PM, who performs surgery at both Chartercare hospitals, she informed the surveyor that the above 2 cases scheduled for 10/19/2023 at the Roger Williams hospital were cancelled due to the lack of equipment/supplies, relative to vendor not being paid. She stated that as of this date, one has yet to be rescheduled and one, she performed at another facility.

3. Patient ID # 3 was scheduled for an endoscopy procedure on 10/24/2023 and was notified that the procedure was cancelled. The booking sheet provided states "supply issue no Balloons".

4. Patient ID # 4 was scheduled for an endoscopy procedure on 10/24/2023 and was notified that the procedure was cancelled. The booking sheet provided states ' ...we need this however we cannot get the stents until the hospital pays the bills to Boston Scientific. Once that happens, we could book ..." signed by Physician, Staff C on 10/25/2023.

5. Patient ID # 5 was scheduled for an endoscopy procedure on 10/24/2023 and was notified that the procedure was cancelled. The booking sheet provided has a handwritten note which states "Pending Boston Scientific".

6. Patient ID # 6 was scheduled for an endoscopy procedure on 10/24/2023 and was notified that the procedure was cancelled. The booking sheet provided to the surveyor states "we need to book once the balloons are in.." signed by Physician, Staff C on 10/26/2023.

During an interview on 10/31/2023 at 11:15 AM, with the OR (Operating Room) Director, and the Administrator of Surgical Services, Staff A, relative to the complaint of cancelled surgical procedures. They provided the operating room schedules for October 2023. The schedules identified 2 orthopedic surgeries scheduled for 10/19/2023, and 4 patients scheduled for endoscopic procedures on 10/24/2023 and 10/25/2023. Staff A informed the surveyor that the hospital can obtain some supplies and equipment from their other facility, and from other hospitals that they have working relationships with. She stated that they are also trying to obtain the necessary equipment from other vendors who have similar products. Staff A informed the surveyor that for October the hospital had 5 endoscopic procedures and 2 orthopedic surgeries.

During an interview on 10/31/2023 at 1:30 PM, with the Gastroenterologist, Staff C, whose procedures had been cancelled, he acknowledged that there have been supply issues and that orders from Boston Scientific were on hold. He said that the hospital needs "balloons" and "stents" for certain procedures and that due to outstanding bill with the company they will not send any supplies at this time. He stated that the hospital is making arrangements to obtain the supplies though another company. Additionally, he stated that they have told some referring physicians to seek other venues for their cases as they cannot perform the procedures at this time.

During an interview with the Chief of Medicine, Staff D , on 10/31/2023, he stated that he had "heard something about stipends not being paid to physicians. He stated that he has not heard about the orthopedic or the endoscopy cases being cancelled in October. He said that he usually will hear from the doctors if they are having concerns. He said he was aware of the cyber attack which cause a delay for about a month.

On 10/31/2023 at approximately 1:30 PM via phone interview, the surveyor spoke with the Director of Supply Chain, Staff E, who stated that the last 4-6 weeks they have had an increase in the number of vendors on credit holds. He stated that there were currently 251 vendors who had placed the hospital on credit holds due to unpaid accounts. He stated that there have been credit holds on accounts for approximately the past 13-14 months. He stated that some of the vendors will release some supplies, some will send a portion of the requested orders, and some will not send any more until the past due amounts are paid. He stated that it changes weekly depending on what companies are paid. The hospital meets daily or every other day and make determinations as to which accounts will be paid. The finance team and team leaders meet to review what is critical and that information is then reported to the CEO and leadership team.

During an interview with the CEO on 11/1/2023, he stated that he was unaware of the endoscopy cases cancelled. He was also unaware that the cases were cancelled due to a credit hold on the company Boston Scientific which provides the supplies necessary to complete the procedures. Additionally, he reports he has daily meetings relative to the finances and that the hospital is on credit holds with some vendors as the hospital does not receive enough money from "California" to cover all the expenses.

Based on record review and staff interview it has been determined that the hospital's corporate parent company failed to provide funding necessary for the Chief Executive Officer who is responsible for managing the hospital, to make sufficient payments to its vendors resulting in several unpaid vendor accounts. This failure to pay these vendor accounts resulted in the cancellation of several scheduled surgeries.

The surveyor interviewed the OR (Operating Room) Director, and the Administrator of Surgical Services Staff A, on 10/31/2023 at 11:15 AM relative to the physician complaint of surgeries being cancelled due to the hospital not paying vendors, resulting in the vendors refusing to fill orders for supplies/equipment necessary for procedures. Review of the OR schedules for October 2023 revealed that 2 orthopedic surgeries have been cancelled and 4 endoscopy procedures at this hospital due to lack of supplies/ equipment necessary to safely perform the procedures.

They provided the schedules which identified the 2 orthopedic surgeries scheduled for 10/19/2023, and 2 patients scheduled for endoscopic procedures on 10/24/2023 as well as 2 endoscopic procedures with booking requests which could not be booked. Staff A informed the surveyor that the hospital can obtain some supplies and equipment from their other facility, and from other hospitals that they have working relationships with. She stated that they are also trying to obtain the necessary equipment from other vendors who have similar products. Staff A informed the surveyor that for October the hospital had 5 endoscopic procedures, and 2 orthopedic surgeries that were canceled due to supply issues.

On 10/31/2023 at 1:30 PM, the surveyor interviewed the Gastroenterologist, Staff C, whose procedures had been cancelled. He acknowledged that there have been supply issues and that orders from Boston Scientific were on hold. He said that the hospital needs "balloons" and "stents" for certain procedures and that due to outstanding bills with the company they will not send any supplies at this time. He stated that the hospital is making arrangements to obtain the supplies though another company. He stated that they have told some referring physicians to seek other venues for their cases as they cannot perform the procedures at this time.

The surveyor interviewed the Chief of Medicine, Staff D , who stated that he had "heard something about stipends not being paid to physicians". He stated that he has not heard about the orthopedic or the endoscopy cases being cancelled in October. He said that he usually will hear from the doctors if they are having concerns. He said he was aware of the cyber-attack which caused a delay for about a month.

The surveyor met with the CEO on 11/1/2023 at 11:00 AM, to review the findings relative to surgical procedures being cancelled related to vendors not being paid resulting in equipment and supplies not being delivered to the hospital. He informed the surveyor that he is given a certain amount of money each week, and that he never knows how much money that will be. Once the hospital has the allowance the team at the hospital meets to determine which bills will be paid, and which vendors will be paid. He stated that there is never enough money to pay all the accounts that are due. He stated that the local RWMC board manages clinical issues and the "Prospect" board has to do with finances. He reports recently the hospital has been receiving less money. He stated that 3 - 4 years ago they would receive adequate money to pay the hospital's bills, and not have vendors on credit holds. He stated that during the cyber-attack which affected all the "Prospect" facilities, this caused a shut down for 5-6 weeks during which time the bills could not be sent out. When asked if the Board of Directors were aware of the cancellation of surgical procedures related to this, he stated they were not aware.

The hospital was unable to produce evidence that the CEO was able to manage the hospital finances, as evidenced by the number of vendors placed on credit hold due to lack of payment resulting in the failure to obtain necessary supplies/equipment necessary resulting in 6 surgical procedures being cancelled in October 2023.