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Based on "Medical Staff Bylaws" review, "Pershing General Hospital District Board of Trustees for Critical Access Hospital Bylaws" review, "Pershing General Hospital District Board of Trustees for Critical Access Hospital Meeting Minutes" review, record review, job description review, observation, and interview, the Critical Access Hospital (CAH) failed to meet the Condition of Participation of Organization Structure. The CAH failed to ensure "Medical Staff Bylaws" were implemented, and the Governing Body failed to assume responsibility for ensuring staff were dedicated to provide care and services to patients residing in the CAH. This failure had the potential to affect all patients receiving care at the CAH.

Findings include:

Cross Reference A0962 - The CAH failed to ensure "Medical Staff Bylaws" were implemented for pronouncement of patient death and the Governing Body or Responsible Individual failed to ensure the CAH had dedicated staff to provide care and services to patients.

Based on "Medical Staff Bylaws" review, "Pershing General Hospital District Board of Trustees for Critical Access Hospital Bylaws" review, "Pershing General Hospital District Board of Trustees Regular Board Meeting Minutes" review, record review, job description review, observation, and interview, the Critical Access Hospital (CAH) Governing Body failed to 1. ensure "Medical Staff Bylaws" were implemented and failed to assume responsibility for ensuring social service and activity staff had dedicated time to provide care and services to patients in the CAH and 2. to ensure a physician or practitioner pronounced death for one of one patient reviewed for death (Patient (P) 7) out of a total sample of 20 patients. This failure had the potential to affect all patients receiving care at the CAH.

Findings include:

Review of the "Pershing General Hospital District Board of Trustees for Critical Access Hospital Bylaws" last revised on 01/26/23 revealed, " ...The Board shall select and employ a competent Administrator in accordance with a written job description as provided by the Board, who shall be a direct representative of the Board in the management of the Hospital. The Administrator shall be given the necessary authority and responsibility to operate the Hospital in all its activities and departments, subject to policies enacted by the Board. The Administrator shall act as the duly authorized representative of the Board in all matters in which the Board has not formally designated some other person to act ...."

Review of the "Pershing General Hospital District Board of Trustees Regular Board Meeting Minutes" dated 01/23/25, 02/27/25, 03/20/25, 03/27/25, 04/24/25, and 05/07/25 did not include any discussion was conducted related to CAH staffing.

Review of the "Pershing General Hospital and Nursing Home Role Summary for Director of Social Worker/Nutrition" with a revision date of 12/13/2024 revealed, " ...The Director, Social Worker/Nutrition is a professional who plays a vital role in the healthcare team by providing essential support to patients, residents, their families, and caregivers. ...Oversees the Activities Department and participates in activities with residents ...This position is responsible for assessing the nutritional related needs of the Nursing Home, Hospital, and the Community. ...Performs initial, quarterly, and annual nutrition assessments and MDS on residents and patients in a timely manner and cost-effective services are provided ...This position typically requires work indoors at the hospital and long-term care unit ...."

Review of the "Pershing General Hospital and Nursing Home Role Summary for Activities Assistant" with a revision date of 05/01/2024 revealed, " ...Under the guidance of the Certified Activities Professional and Social Worker, the Activities Assistant will provide group and individual activities for the residents of the Pershing General Hospital's Long-Term-Care facilities ...."

1. Observation on 06/17/25 at 9:00 AM identified a building with the name Pershing General Hospital and Nursing Home on the outside of the building. There was a double door to enter the building. Inside the main lobby of the building there were double doors on the left to enter the CAH and double doors on the right to enter the LTC facility. Once inside the CAH there were two additional doors that could be used to access the LTC facility.

During an interview on 06/18/25 at 9:34 AM, the Activity Assistant (Act Asst) stated he/she was hired by the CAH on 01/21/25 and works 32 hours a week. The Act Asst. stated he/she works on both the CAH side of the building and the long-term care (LTC) nursing home side. The Act Asst. stated that when he/she started the CAH patients would go to the LTC for activity programs and leisure time. The hospital stopped the CAH patients from going to LTC for a period of time but resumed the co-mingling of activities between the CAH and LTC residents in June 2025. The Act Asst. stated there is one June 2025 activity calendar that includes activities for both CAH patients and LTC residents. The Act Asset. stated that the bingo activity today (06/18/25) at 10:15 AM will be held for both CAH patients and LTC residents in the LTC facility's dining room. The Act Asst. stated he/she works Monday through Thursday eight hours shifts. The Act Asst. stated he/she spends Monday and Thursday mornings from around 10:00 AM to 11:30 AM in the hospital (CAH) to conduct room visits with the traveling library cart and the rest of the day is spent in the LTC facility. The Act Asst. stated all activities listed on the June 2025 activity calendar are for both CAH and LTC and are held in the dining room of the LTC facility. Before every activity, he/she goes around and asks every patient in the CAH if they want to attend the activity which takes place in the LTC facility. The Act Asst. stated he/she works on "both sides" every day. The Act Asst. stated the LTC staff do not know the CAH patients, but she knows patients on both sides, because she works with them.

During an interview on 06/18/25 at 10:05 AM, the Administrator stated the Act Asst. does not log his/her time to show the separate time spent with CAH patients and LTC residents.

During an interview on 06/18/25 at 10:17 AM, the Licensed Medical Social Worker (LMSW) stated he/she was hired by the CAH on 06/01/23 as a 40 hour a week salary social worker for the Rural Health Clinic (RHC), LTC, and the CAH. The LMSW stated he/she has filled out the "Social Service Time Spent By Service" log since she was hired at the CAH to keep track of how much time in minutes he/she spends each day in each department (LTC, CAH, and RHC). The LMSW confirmed he/she is responsible for social services for the CAH, RHC, and LTC facility. The LMSW stated he/she tried to categorize his/her time, such as block scheduling (dedicated days to each entity), but it did not work. The LMSW stated due to the timing of required assessments in LTC and activity that occurs in the emergency room of the CAH, he/she spends time each day in the CAH and LTC facility. The LMSW stated she "bounces back and forth" every day to get the work done.

During an interview on 06/19/25 at 2:02 PM, the Medical Director stated he/she was aware that social service staff and activity staff are not distinct to the CAH. The Medical Director stated he/she was aware of the intermingling of CAH staff with the LTC facility and there were multiple discussions about it a few months ago. There was a discussion about rotating activity staff, and they were trying to sort out what was required by the regulations. The Medical Director stated he/she was aware the social worker was "bouncing" between the two entities (CAH and LTC) because it was difficult to get staff in the hospital location. The Medical Director stated he/she attends the Board of Trustees (Governing Body) meetings remotely and did not recall if the intermingling of CAH staff in the LTC facility was ever formally brought up. The Medical Director stated he/she has talked about the staffing issue with the Administrator but was unaware of any action taken by the Governing Body or Administrator. The Medical Director stated there is not a lot of knowledge about CAH regulations, and he/she has identified a need to address this with Medical Staff and hospital staff.

During an interview on 06/19/25 at 4:24 PM, the Administrator stated CAH staff, including the LMSW and Act Asst work at various times of each day between the CAH and the LTC facility. The Administrator stated he/she was told by a state surveyor that it was all right to have CAH staff intermingle between the CAH and the LTC. The Administrator stated it was his/her understanding that if a time study were used, the CAH staff could intermingle between the LTC and CAH, because one company owned the facilities and there was one payroll system. The Administrator stated the hospital makes efforts to get staff but due to the location it is difficult, so staff carry many hats. The Administrator stated the Centers for Medicare and Medicaid (CMS) views the CAH, Rural Health Clinic (RHC), and LTC facilities as separate because they have separate CMS Certification Number (CCN), but because they have the same owner, he/she considers them one entity. The Administrator stated he/she did not bring the intermingling of CAH staff in the LTC facility to the Governing Body because he/she believed it was an acceptable practice.

2. Review of the critical access hospital's (CAH) "Medical Staff Bylaws," adopted by the Governing Board on 03/24/23, indicated ". . . The term "Practitioner" shall refer to a Doctor of Medicine (MD), Doctor of Osteopathy (DO), advanced practice [sic] Registered Nurse (APRN), and Physician Assistant Certified (PA-C) . . . Rules and Regulations . . . In the event of a hospital death, the deceased shall be pronounced dead by physician or practitioner . . . Pronouncement of death shall be completed within a reasonable length of time, following notification by the nursing service of such death. . ."

Review of P7's electronic medical record (EMR) "Demographic" tab, then the "Face Sheet" tab indicated P7 was admitted on 06/16/24 at 10:06 PM.

Review of P7's "Order Chronology" located under the "Order Chronology" tab in the EMR indicated P7's diagnosis was documented on 06/16/24 at 10:20 PM as acute respiratory failure with hypoxia.

Review of P7's "Patient Progress Notes" located under the "Clinical History" tab, then the "Patient Progress Notes" tab in the EMR revealed Registered Nurse (RN) 1 documented on 06/17/24 at 2:25 AM "In to check on Pt. [patient] Pt has no respirations and no pulse. On auscultation heart and lung sounds are absent and confirmed by second RN. Provider notified and verbal order for RN to pronounce obtained. Pt pronounced deceased at 0225 [2:25 AM]."

During an interview on 06/18/25 at 12:40 PM, Chief Nursing Officer (CNO) stated P7's EMR had no physician order to release P7's body and/or for RN1 to pronounce death.

During an interview on 06/19/25 at 2:02 PM, the Medical Director stated it had been the practice that the RN pronounced death for about 10 years. Medical Director stated he/she was not aware the hospital's Medical Staff Bylaws had the requirement that a physician or practitioner had to pronounce patient death.

Based on "Social Services Time Spent By Service Type" log review, "June 2025" activity calendar review, job description review, observation, and interview, the Critical Access Hospital (CAH) failed to meet the Condition of Staffing and Staff Responsibilities. The CAH failed to ensure CAH social service and recreation activity staff had distinct and dedicated shifts to provide care and services to patients residing in the CAH. This failure had the potential to affect all patients receiving care at the CAH.

Findings include:

Observation on 06/17/25 at 9:00 AM identified a building with the name Pershing General Hospital and Nursing Home affixed to the outside of the building. There was a double door to enter the building. Inside the main lobby of the building there were double doors on the left to enter the CAH and double doors on the right to enter the Nursing Home (Long Term Care (LTC)) facility. Once inside the CAH there were two additional doors that could be used to access to the LTC facility.

Review of the "Pershing General Hospital and Nursing Home Role Summary for Director of Social Worker/Nutrition" with a revision date of 12/13/2024 revealed, " ...The Director, Social Worker/Nutrition is a professional who plays a vital role in the healthcare team by providing essential support to patients, residents, their families, and caregivers. ...Oversees the Activities Department and participates in activities with residents ...This position is responsible for assessing the nutritional related needs of the Nursing Home, Hospital, and the Community. ...Performs initial, quarterly, and annual nutrition assessments and MDS on residents and patients in a timely manner and cost-effective services are provided ...This position typically requires work indoors at the hospital and long-term care unit ...."

Review of the "Pershing General Hospital and Nursing Home Role Summary for Activities Assistant" with a revision date of 05/01/2024 revealed, " ...Under the guidance of the Certified Activities Professional and Social Worker, the Activities Assistant will provide group and individual activities for the residents of the Pershing General Hospital's Long-Term-Care facilities ...."

Review of the "Social Services Time Spent By Service Type" log dated April, May, and June fiscal year 2024 revealed, " ...June 12 - 300 minutes under Med-[Medical-Surgical], 120 minutes under LTC ...June 13 - 300 minutes under Med-Surg, 30 minutes under ER [emergency room], 120 minutes under LTC ...June 16 - 60 minutes under Med-Surg, 180 minutes under ER, 300 minutes under LTC ...June 17 - 120 minutes under ER, 360 minutes under LTC ...."

Review of the "June 2025" activity calendar revealed, "..Monday June 2- 9:30am Move to the Music, 10 am Room visits w/Traveling Library, 1:30pm Bingo ...Thursday June 12- 9:30 am Move to the Music, 10 am Outing to the Senior Center for Lunch, 3 pm Bingo ...Wednesday June 11- 9:30 am Move to the Music, 10:15 am Bingo, 1 pm Painting with the Kids, 2pm Catholic Service ..."

During an interview on 06/18/25 at 9:34 AM, the Activity Assistant (Act Asst.) stated he/she was hired by the CAH on 01/21/25 and works 32 hours a week. The Act Asset. stated he/she works on both the CAH side of the building and the long term care (LTC) nursing home side. The Act Asst stated that when he/she started employment, the CAH patients would go to the LTC side for activity programs and leisure time. The hospital stopped the CAH patients from going to LTC for a period of time but resumed the co-mingling of activities between the CAH and LTC residents in June 2025. The Act Asst. stated there is one June 2025 recreation activity calendar that includes activities for both CAH patients and LTC residents. The Act Asst stated that the bingo activity today (06/18/25) at 10:15 AM will be held for both CAH patients and LTC residents in the LTC facility's dining room. The Act Asst. stated he/she works Monday through Thursday eight hours shifts. The Act Asst stated he/she spends Monday and Thursday mornings from around 10:00 AM to 11:30 AM in the hospital (CAH) to conduct room visits with the traveling library cart and the rest of the day is spent in the LTC facility. The Act Asst stated all activities listed on the June 2025 activity calendar are for both CAH and LTC and are held in the dining room of the LTC facility. Before every activity, he/she goes around and asks every patient in the CAH if they want to attend the activity which takes place in the LTC facility. The Act Asst stated he/she works on "both sides" (CAH and LTC) every day. The Act Asset. stated the LTC staff don't know the CAH patients, but she knows patients on both sides, because she works with them. The Act Asst stated he/she does not document the amount of time each day that is spent in the CAH.

During an interview on 06/18/25 at 10:05 AM, the Administrator stated the Act Asst. does not log his/her time to show the separate/distinct time that is spent with CAH patients and LTC residents.

During an interview on 06/18/25 at 10:17 AM, the Licensed Medical Social Worker (LMSW) stated he/she was hired by the CAH on 06/01/23 as a 40 hour a week salary social worker for the Rural Health Clinic (RHC), LTC, and the CAH. The LMSW stated he/she has filled out the "Social Service Time Spent By Service" log since being hired at the CAH to keep track of how much time in minutes he/she spends each day in each department (LTC, CAH, and RHC). The LMSW confirmed he/she is responsible for social services for the CAH, RHC, and LTC facility. The LMSW stated he/she tried to categorize his/her time, such as block scheduling (dedicated days to each entity), but it didn't work. The LMSW stated due to the timing of required assessments in LTC and activity that occurs in the emergency room of the CAH, he/she spends time each day in the CAH and LTC facility. The LMSW stated she "bounces back and forth" every day to get the work done.

During an interview on 06/19/25 at 2:02 PM, the Medical Director stated he/she was aware that social worker staff and activity staff are not distinct to the CAH. The Medical Director stated he/she was aware of the intermingling of CAH staff with the LTC facility and there were multiple discussions about it a few months ago. There was a discussion about rotating activity staff, and they were trying to sort out what was required by the regulations. The Medical Director stated he/she was aware the social worker was "bouncing" between the two entities (CAH and LTC) because it was difficult to get staff in the hospital's location. The Medical Director stated there is not a lot of knowledge about CAH regulations, and he/she has identified a need to address this with Medical Staff and hospital staff.

During an interview on 06/19/25 at 4:24 PM, the Administrator stated CAH staff, including the LMSW and Act Asset. work at different times of each day between the CAH and the LTC facility. The Administrator stated he/she was told by a state surveyor that it was alright to have CAH staff intermingle between the CAH and the LTC facility. The Administrator stated it was his/her understanding that if a time study was used, the CAH staff could intermingle between the LTC and CAH, because one company owned the facilities and there was one payroll system. The Administrator stated the hospital makes efforts to get staff but due to the location it is difficult, so staff carry many hats. The Administrator stated the Centers for Medicare and Medicaid (CMS) views the CAH and LTC facilities as separate because they each have separate CMS Certification Number (CCN), but because they have the same owner, he/she considers the CAH and LTC as one entity.

Based on policy review, patient record reviews, and interview, the critical access hospital (CAH) failed to ensure each patient record had documentation of a nutritional assessment performed by the Registered Nurse (RN) at the time of the initial nursing admission assessment for five (Patient (P) 12, P13, P14, P15, P16) of 11 patient records reviewed for nutritional assessments from a total sample of 20 patients. This deficient practice had the potential for unidentified nutritional needs of patients.

Findings include:

Review of the hospital policy titled "Provision of Care," reviewed 10/25/24, indicated ". . . Each patient receives an assessment upon admission, creating an individualized care plan. Plans are updated based on patient needs and progress, with coordination across interdisciplinary teams. . . Documentation encompasses assessments, care plans, treatments, and patient progress. . ." Review of the policy indicated the policy did not address the specific patient services/systems that needed to be assessed.

1. Review of P 12' s' electronic medical record (EMR) "Demographic Header" indicated P12 was admitted on 10/22/24 at 4:38 PM with a chief complaint of pneumonia.

Review of P12's "Nutrition Risk Screen/Initial Assessment" documented on 10/23/24 and located under the "Clinical History" tab, then the "Nursing" check box indicated P12's level of nutritional risk was not documented, and the nurse performing the assessment did not sign the assessment.

During an interview on 06/19/25 at 10:56 AM, Nurse Administrative Coordinator (NAC) (who is an RN) verified that the nutritional risk was not documented, and that the RN performing the assessment did not sign the assessment.

2. Review of 13's EMR "Demographic Header" indicated P13 was admitted on 11/19/24 at 6:30 PM with the chief complaint of acute pancreatitis found in P13's history and physical located under the "Notes" tab.

Review of P13's "Nutrition Risk Screen/Initial Assessment" documented on 11/19/24 and located under the "Clinical History" tab, then the "Nursing" check box indicated the level of nutritional risk was not documented, and the nurse performing the assessment did not sign the assessment.

During an interview on 06/19/25 at 11:33 AM, NAC (who is an RN) verified the nutritional risk was not documented, and the RN performing the assessment did not sign the assessment.

3. Review of P 14' s' EMR "Demographic Header" indicated P14 was admitted on 12/04/24 at 6:09 PM with the chief complaint of shortness of breath. Review of P14's EMR indicated there was no documentation that the RN had performed a nutritional risk screen.

During an interview on 06/19/25 at 12:03 PM, NAC (who is an RN) verified the "Nutrition Risk Screen/Initial Assessment" form was not completed by the RN for P14.

4. Review of P 15' s' EMR "Demographic Header" indicated P15 was admitted on 12/23/24 at 2:52 PM with chief complaints of sepsis and cellulitis of the right lower extremity documented in P15's history and physical located under the "Notes" tab.

Review of P15's "Nutrition Risk Screen/Initial Assessment" documented on 12/23/24 under the "Clinical History" tab, then the "Nursing" check box indicated the listed lab work results were not documented, and the level of nutritional risk was not documented.

During an interview on 06/19/25 at 12:20 PM, NAC (who is an RN) verified the "Nutrition Risk Screen/Initial Assessment" form for P15 was incomplete. NAC stated the form did not include the lab results and/or the level of nutritional risk.

5. Review of P16's EMR "Demographic Header" indicated P16 was admitted on 01/15/25 at 11:39 AM with a chief complaint of generalized weakness documented in P16's history and physical located under the "Notes" tab.

Review of P16's "Nutrition Risk Screen/Initial Assessment located under the EMR "Clinical History" tab, then the "Nursing" check box indicated the date of the assessment and/or the level of nutritional risk were not documented.

During an interview on 06/19/25 at 12:39 PM, NAC (who is an RN) verified the "Nutrition Risk Screen/Initial Assessment" form for P16 was incomplete. NAC stated the form did not include the date the assessment was performed and/or the level of nutritional risk.

Based on policy review, record review, and interviews, the critical access hospital (CAH) failed to ensure each patient had a nursing care plan developed and kept current for three (Patient (P) 11, P12, and P18) of 11 patient EMRs reviewed for a current nursing care plan from a total sample of 20 patients. This deficient practice had the potential to affect all inpatients receiving services in the critical access hospital (CAH).

Findings include:

Review of the CAH's policy titled "Provision of Care," reviewed 10/25/24, indicated ". . . Each patient receives an assessment upon admission, creating an individualized care plan. Plans are updated based on patient needs and progress, with coordination across interdisciplinary teams. . ."

1. Review of P 11' s' EMR "Demographic Header" indicated P11 was admitted on 09/29/24 at 8:40 PM with diagnoses of COVID [Coronavirus disease] positive and hypoxia.

Review of P11's EMR, navigated by Nursing Administrative Coordinator (NAC) who was a registered nurse (RN), indicated no documentation of a nursing care plan that included patient problems/needs that had been assessed, goals to be met, and/or interventions to be performed.

During an interview on 06/19/25 at 10:18 AM, NAC stated in September 2024 that the nurses were not developing a care plan for the acute inpatients but instead documented a problem and intervention in the progress notes.

2. Review of P 12' s' EMR "Demographic Header," navigated by NAC who was an RN indicated P12 was admitted on 10/22/24 at 4:38 PM . Review of P12's history and physical (located under the "Notes" tab) documented on 10/22/24 at 6:09 PM indicated P12's chief complaint was pneumonia.

Review of P12's 10/23/24, 10/24/24, and 10/25/24 "Patient Progress Notes" located under the "Clinical History" tab, then "Nursing" box checked.) dated indicated problems with interventions documented but no goals documented.

During an interview on 06/19/25 at 10:57 AM, NAC stated a nursing care plan was not developed for P12 that included patient problems/needs that had been assessed, goals to be met, and interventions to be performed.

3. Review of P18's EMR located under the "Demographics" tab revealed P18 was admitted to the hospital on 05/11/25.

Review of a physician "Admission Note" dated 05/11/25 located in the EMR under the "Clinical Records" tab revealed, " ...clinical impression cellulitis of the left lower leg, history of atrial fibrillation, neuropathy ...admit for IV [intravenous] antibiotics ...."

Review of the "Orders" located in the EMR under the "Order Chronology" tab revealed an order dated 05/11/25 to admit P18 to the CAH and on order dated 05/15/25 to "discharge to Swing."

Review of the EMR on 06/18/25 did not reveal that a care plan was initiated for P18's admission to the CAH.

During an interview on 06/18/25 at 2:20 PM, the Nurse Administrator Coordinator (NAC) confirmed a care plan was not located in P18's EMR. NAC could not explain why a care plan was not developed for P18 after admission.

Based on policy review, medical record review, and interview, the critical access hospital (CAH) failed to ensure documentation of the patient's transfer form was complete for one (Patient (P) 10) of three transferred patients reviewed from a total sample of 20 patients. This deficient practice had the potential to affect all inpatients and emergency department patients receiving services and transferred by the CAH.

Findings include:

Review of the CAH policy titled "Medical Records - Content of Health Record," reviewed 04/28/25, indicated ". . . This hospital shall ensure that the medical record shall contain sufficient information to: . . . Accurately document the course and results of care, treatment, and services . . ."

Review of P10's electronic medical record (EMR) "Demographic Header," navigated by Revenue Cycle Manager (RCM), indicated P10 was admitted on 07/01/24 at 2:30 PM.

Review of P10's "Discharge Summary" located in the EMR under the "Notes" tab documented on 07/02/24 P10 was admitted with a diagnosis of hyponatremia (low sodium levels).

Review of P10's "Patient's Consent/Request/Refusal to be Transferred" documented on 07/02/24 at 7:27 PM located in the EMR "Transfer" tab under the "Scanned Images" tab revealed the name of the person receiving report at the receiving hospital and other medical risks were not documented on the form.

During an interview on 06/18/25 at 3:11 PM, RCM verified that the name of the person receiving report at the receiving hospital and other medical risks were not documented on P10's transfer form. RCM stated the CAH did not have a specific policy related to completion of a patient's transfer form.

Based on record review, "Admit Packet" review, document review, and interview, the Critical Access Hospital (CAH) failed to provide Medicaid information to patients who had Medicaid benefits on admission or became eligible for Medicaid benefits during admission for four of six sampled Swing (Patients (P) 1, P3, P4, and P6) from a total sample of 20 patients. This failure had the potential to affect patients admitted to the CAH with Medicaid benefits or who become eligible during their hospital stay.

Findings include:

1. Review of P1's "Face Sheet" located in the electronic Medical Record (EMR) under the "Demographics" tab revealed P1 was admitted to the hospital on 06/03/25 under Medicaid benefits.

Review of the "Admit Packet" (that includes information provided to patients on admission to the hospital) dated 06/03/25 located in the EMR under the "Scan Images" tab did not reveal P1 was provided with information related to services included under the State plan and items and services the hospital offers and which the patient may be charged with the amount for the services.

2. Review of P3's "Face Sheet" located in the EMR under the "Demographics" tab revealed P3 was admitted to the hospital on 05/27/25 under Medicaid benefit.

Review of the "Admit Packet" (that includes information provided to patients on admission to the hospital) dated 05/27/25 located in the EMR under the "Scan Images" tab did not reveal P3 was provided with information related to services included under the State plan and items and services the hospital offers and which the patient may be charged with the amount for the services.

3. Review of P4's "Face Sheet" located in the EMR under the "Demographics" tab revealed P4 was admitted to the hospital on 12/26/24 under Medicaid benefit.

Review of the "Admit Packet" (that includes information provided to patients on admission to the hospital) dated 12/26/24 located in the EMR under the "Scan Images" tab did not reveal P4 was provided with information related to services included under the State plan and items and services the hospital offers and which the patient may be charged with the amount for the services.

4. Review of P6's "Face Sheet" located in the EMR under the "Demographics" tab revealed P6 was admitted to the hospital on 07/25/24 under Medicare A benefit.

Review of the "State of Nevada Department of Health and Human Services Division of Welfare and Supportive Services " provided by the social worker revealed P6 received approval for Medicaid benefits on 05/21/25.

Review of the "Admit Packet" (that includes information provided to patients on admission to the hospital) dated 07/25/24 located in the EMR under the "Scan Images" tab did not reveal P6 was provided with information related to services included under the State plan and items and services the hospital offers and which the patient may be charged with the amount for the services.

Review of the EMR did not reveal that after P6 became eligible for Medicaid benefits on 05/21/25, Medicaid information was provided by the hospital.

During an interview on 06/18/25 at 10:20 AM, the Licensed Medical Social Worker (LMSW) stated he/she has never provided Medicaid information to Medicaid eligible patients. The LMSW stated Medicaid covers everything while patients are in the hospital and he/she did not see the reason to provide the information.

During an interview on 06/18/25 at 3:00 PM, the Revenue Cycle Manager (RCM) stated he/she oversees providing the Admit Packet to patients on admission to the hospital. The RCM confirmed the hospital does not provide Medicaid benefit information to patients on admission. The RCM stated the hospital does not have a policy that directs what is included in the Admit Packet.

Based on record review, "Admit Packet" review, document review, and interview, the Critical Access Hospital (CAH) failed to provide Medicaid information to patients who had Medicaid benefits on admission or became eligible for Medicaid benefits during admission for four of six sampled Swing (Patients (P) 1, P3, P4, and P6) from a total sample of 20 patients. This failure had the potential to affect patients admitted to the CAH with Medicaid benefits or who become eligible during their hospital stay.

Findings include:

1. Review of P1's "Face Sheet" located in the electronic Medical Record (EMR) under the "Demographics" tab revealed P1 was admitted to the hospital on 06/03/25 under Medicaid benefits.

Review of the "Admit Packet" (that includes information provided to patients on admission to the hospital) dated 06/03/25 located in the EMR under the "Scan Images" tab did not reveal P1 was provided with information related to services included under the State plan and items and services the hospital offers and which the patient may be charged with the amount for the services.

2. Review of P3's "Face Sheet" located in the EMR under the "Demographics" tab revealed P3 was admitted to the hospital on 05/27/25 under Medicaid benefit.

Review of the "Admit Packet" (that includes information provided to patients on admission to the hospital) dated 05/27/25 located in the EMR under the "Scan Images" tab did not reveal P3 was provided with information related to services included under the State plan and items and services the hospital offers and which the patient may be charged with the amount for the services.

3. Review of P4's "Face Sheet" located in the EMR under the "Demographics" tab revealed P4 was admitted to the hospital on 12/26/24 under Medicaid benefit.

Review of the "Admit Packet" (that includes information provided to patients on admission to the hospital) dated 12/26/24 located in the EMR under the "Scan Images" tab did not reveal P4 was provided with information related to services included under the State plan and items and services the hospital offers and which the patient may be charged with the amount for the services.

4. Review of P6's "Face Sheet" located in the EMR under the "Demographics" tab revealed P6 was admitted to the hospital on 07/25/24 under Medicare A benefit.

Review of the "State of Nevada Department of Health and Human Services Division of Welfare and Supportive Services " provided by the social worker revealed P6 received approval for Medicaid benefits on 05/21/25.

Review of the "Admit Packet" (that includes information provided to patients on admission to the hospital) dated 07/25/24 located in the EMR under the "Scan Images" tab did not reveal P6 was provided with information related to services included under the State plan and items and services the hospital offers and which the patient may be charged with the amount for the services.

Review of the EMR did not reveal that after P6 became eligible for Medicaid benefits on 05/21/25, Medicaid information was provided by the hospital.

During an interview on 06/18/25 at 10:20 AM, the Licensed Medical Social Worker (LMSW) stated he/she has never provided Medicaid information to Medicaid eligible patients. The LMSW stated Medicaid covers everything while patients are in the hospital and he/she did not see the reason to provide the information.

During an interview on 06/18/25 at 3:00 PM, the Revenue Cycle Manager (RCM) stated he/she oversees providing the Admit Packet to patients on admission to the hospital. The RCM confirmed the hospital does not provide Medicaid benefit information to patients on admission. The RCM stated the hospital does not have a policy that directs what is included in the Admit Packet.

Based on "Medical Staff Bylaws" review, "Pershing General Hospital District Board of Trustees for Critical Access Hospital Bylaws" review, "Pershing General Hospital District Board of Trustees Regular Board Meeting Minutes" review, record review, job description review, observation, and interview, the Critical Access Hospital (CAH) Governing Body failed to 1. ensure "Medical Staff Bylaws" were implemented and failed to assume responsibility for ensuring social service and activity staff had dedicated time to provide care and services to patients in the CAH and 2. to ensure a physician or practitioner pronounced death for one of one patient reviewed for death (Patient (P) 7) out of a total sample of 20 patients. This failure had the potential to affect all patients receiving care at the CAH.

Findings include:

Review of the "Pershing General Hospital District Board of Trustees for Critical Access Hospital Bylaws" last revised on 01/26/23 revealed, " ...The Board shall select and employ a competent Administrator in accordance with a written job description as provided by the Board, who shall be a direct representative of the Board in the management of the Hospital. The Administrator shall be given the necessary authority and responsibility to operate the Hospital in all its activities and departments, subject to policies enacted by the Board. The Administrator shall act as the duly authorized representative of the Board in all matters in which the Board has not formally designated some other person to act ...."

Review of the "Pershing General Hospital District Board of Trustees Regular Board Meeting Minutes" dated 01/23/25, 02/27/25, 03/20/25, 03/27/25, 04/24/25, and 05/07/25 did not include any discussion was conducted related to CAH staffing.

Review of the "Pershing General Hospital and Nursing Home Role Summary for Director of Social Worker/Nutrition" with a revision date of 12/13/2024 revealed, " ...The Director, Social Worker/Nutrition is a professional who plays a vital role in the healthcare team by providing essential support to patients, residents, their families, and caregivers. ...Oversees the Activities Department and participates in activities with residents ...This position is responsible for assessing the nutritional related needs of the Nursing Home, Hospital, and the Community. ...Performs initial, quarterly, and annual nutrition assessments and MDS on residents and patients in a timely manner and cost-effective services are provided ...This position typically requires work indoors at the hospital and long-term care unit ...."

Review of the "Pershing General Hospital and Nursing Home Role Summary for Activities Assistant" with a revision date of 05/01/2024 revealed, " ...Under the guidance of the Certified Activities Professional and Social Worker, the Activities Assistant will provide group and individual activities for the residents of the Pershing General Hospital's Long-Term-Care facilities ...."

1. Observation on 06/17/25 at 9:00 AM identified a building with the name Pershing General Hospital and Nursing Home on the outside of the building. There was a double door to enter the building. Inside the main lobby of the building there were double doors on the left to enter the CAH and double doors on the right to enter the LTC facility. Once inside the CAH there were two additional doors that could be used to access the LTC facility.

During an interview on 06/18/25 at 9:34 AM, the Activity Assistant (Act Asset.) stated he/she was hired by the CAH on 01/21/25 and works 32 hours a week. The Act Asset. stated he/she works on both the CAH side of the building and the long-term care (LTC) nursing home side. The Act Asst. stated that when he/she started the CAH patients would go to the LTC for activity programs and leisure time. The hospital stopped the CAH patients from going to LTC for a period of time but resumed the co-mingling of activities between the CAH and LTC residents in June 2025. The Act Asst. stated there is one June 2025 activity calendar that includes activities for both CAH patients and LTC residents. The Act Asst. stated that the bingo activity today (06/18/25) at 10:15 AM will be held for both CAH patients and LTC residents in the LTC facility's dining room. The Act Asst. stated he/she works Monday through Thursday eight hours shifts. The Act Asset. stated he/she spends Monday and Thursday mornings from around 10:00 AM to 11:30 AM in the hospital (CAH) to conduct room visits with the traveling library cart and the rest of the day is spent in the LTC facility. The Act Asst. stated all activities listed on the June 2025 activity calendar are for both CAH and LTC and are held in the dining room of the LTC facility. Before every activity, he/she goes around and asks every patient in the CAH if they want to attend the activity which takes place in the LTC facility. The Act Asset. stated he/she works on "both sides" every day. The Act Asst stated the LTC staff do not know the CAH patients, but she knows patients on both sides, because she works with them.

During an interview on 06/18/25 at 10:05 AM, the Administrator stated the Act Asst does not log his/her time to show the separate time spent with CAH patients and LTC residents.

During an interview on 06/18/25 at 10:17 AM, the Licensed Medical Social Worker (LMSW) stated he/she was hired by the CAH on 06/01/23 as a 40 hour a week salary social worker for the Rural Health Clinic (RHC), LTC, and the CAH. The LMSW stated he/she has filled out the "Social Service Time Spent By Service" log since she was hired at the CAH to keep track of how much time in minutes he/she spends each day in each department (LTC, CAH, and RHC). The LMSW confirmed he/she is responsible for social services for the CAH, RHC, and LTC facility. The LMSW stated he/she tried to categorize his/her time, such as block scheduling (dedicated days to each entity), but it did not work. The LMSW stated due to the timing of required assessments in LTC and activity that occurs in the emergency room of the CAH, he/she spends time each day in the CAH and LTC facility. The LMSW stated she "bounces back and forth" every day to get the work done.

During an interview on 06/19/25 at 2:02 PM, the Medical Director stated he/she was aware that social service staff and activity staff are not distinct to the CAH. The Medical Director stated he/she was aware of the intermingling of CAH staff with the LTC facility and there were multiple discussions about it a few months ago. There was a discussion about rotating activity staff, and they were trying to sort out what was required by the regulations. The Medical Director stated he/she was aware the social worker was "bouncing" between the two entities (CAH and LTC) because it was difficult to get staff in the hospital location. The Medical Director stated he/she attends the Board of Trustees (Governing Body) meetings remotely and did not recall if the intermingling of CAH staff in the LTC facility was ever formally brought up. The Medical Director stated he/she has talked about the staffing issue with the Administrator but was unaware of any action taken by the Governing Body or Administrator. The Medical Director stated there is not a lot of knowledge about CAH regulations, and he/she has identified a need to address this with Medical Staff and hospital staff.

During an interview on 06/19/25 at 4:24 PM, the Administrator stated CAH staff, including the LMSW and Act Asst work at various times of each day between the CAH and the LTC facility. The Administrator stated he/she was told by a state surveyor that it was all right to have CAH staff intermingle between the CAH and the LTC. The Administrator stated it was his/her understanding that if a time study were used, the CAH staff could intermingle between the LTC and CAH, because one company owned the facilities and there was one payroll system. The Administrator stated the hospital makes efforts to get staff but due to the location it is difficult, so staff carry many hats. The Administrator stated the Centers for Medicare and Medicaid (CMS) views the CAH, Rural Health Clinic (RHC), and LTC facilities as separate because they have separate CMS Certification Number (CCN), but because they have the same owner, he/she considers them one entity. The Administrator stated he/she did not bring the intermingling of CAH staff in the LTC facility to the Governing Body because he/she believed it was an acceptable practice.

2.Review of the critical access hospital's (CAH) "Medical Staff Bylaws," adopted by the Governing Board on 03/24/23, indicated ". . . The term "Practitioner" shall refer to a Doctor of Medicine (MD), Doctor of Osteopathy (DO), advanced practice [sic] Registered Nurse (APRN), and Physician Assistant Certified (PA-C) . . . Rules and Regulations . . . In the event of a hospital death, the deceased shall be pronounced dead by physician or practitioner . . . Pronouncement of death shall be completed within a reasonable length of time, following notification by the nursing service of such death. . ."

Review of P7's electronic medical record (EMR) "Demographic" tab, then the "Face Sheet" tab indicated P7 was admitted on 06/16/24 at 10:06 PM.

Review of P7's "Order Chronology" located under the "Order Chronology" tab in the EMR indicated P7's diagnosis was documented on 06/16/24 at 10:20 PM as acute respiratory failure with hypoxia.

Review of P7's "Patient Progress Notes" located under the "Clinical History" tab, then the "Patient Progress Notes" tab in the EMR revealed Registered Nurse (RN) 1 documented on 06/17/24 at 2:25 AM "In to check on Pt. [patient] Pt has no respirations and no pulse. On auscultation heart and lung sounds are absent and confirmed by second RN. Provider notified and verbal order for RN to pronounce obtained. Pt pronounced deceased at 0225 [2:25 AM]."

During an interview on 06/18/25 at 12:40 PM, Chief Nursing Officer (CNO) stated P7's EMR had no physician order to release P7's body and/or for RN1 to pronounce death.

During an interview on 06/19/25 at 2:02 PM, the Medical Director stated it had been the practice that the RN pronounced death for about 10 years. Medical Director stated he/she was not aware the hospital's Medical Staff Bylaws had the requirement that a physician or practitioner had to pronounce patient death.

Based on policy review, patient electronic medical record (EMR) review, and interview, the critical access hospital (CAH) failed to ensure physician orders for an occupational therapy (OT) evaluation was implemented for one (Patient (P) 16) of one patient EMR reviewed with orders for an OT evaluation from a total sample of 20 patients. This deficient practice had the potential to affect all inpatients receiving care in the CAH.

Findings include:

Review of the CAH's policy titled "Medical Records - Content of Health Record," reviewed 04/28/25, indicated ". . . The clinical/case record of the individual served shall contain the following clinical information: . . . Findings of assessments and reassessments . . . Response to care, treatment or services . . ."

Review of P16's EMR, navigated by Nurse Administrative Coordinator (NAC) who is a registered nurse (RN), indicated P16 was admitted on 01/15/25 at 11:39 AM (located in the demographic header when the EMR is opened). Review of P16's "Discharge Summary" (located under the "Notes" tab) documented on 01/17/25 indicated P16 was admitted with a diagnosis of acute urinary tract infection. Review of P16's physician orders (located under the "Order Chronology" tab) indicated an order on 01/15/25 for an OT evaluation. Review of P16's EMR indicated no documentation that an OT evaluation had been performed, the reason the evaluation was not performed, and that the physician was notified the OT evaluation was not performed.

During an interview on 06/19/25 at 12:39 PM, NAC confirmed P16's EMR did not have documentation that an OT evaluation had been performed, the reason the evaluation was not performed, and that the physician was notified the OT evaluation was not performed.

Based on policy review, medical record review, and interviews, the critical access hospital (CAH) failed to ensure discharge planning was conducted timely to ensure that arrangements for post-CAH care would be made before discharge and to avoid unnecessary delays in discharge for two (Patient (P) 12, P13) of 11 patient records reviewed for discharge planning from a total sample of 20 patient records. This deficient practice had the potential to affect all inpatients receiving services in the CAH.

Findings include:

Review of the CAH policy titled "Discharge or Transfer of Patient," reviewed 04/18/23, indicated ". . . Discharge assessments shall be completed by an RN [registered nurse] within eight (8) hours of discharge of the patient. . ." There was no documentation in the policy that addressed discharge planning to ensure that arrangements for post-CAH care would be made before discharge and to avoid unnecessary delays in discharge.

Review of the CAH policy titled "Discharge Screening and Planning," reviewed 07/05/24, indicated ". . . Every patient shall be evaluated by social services within 2 [two] days of admission to determine the need for Social Service/Discharge Planning interventions. . . There will be a discharge plan based on his/her individual needs in the electronic health record (EHR). Progress notes will be made throughout the patient's stay to document progress and resources contacted to attain goals for discharge. . ."

1. Review of P12's electronic medical record (EMR) "Demographic Header", navigated by Nurse Administrative Coordinator (NAC) who is an RN, indicated P12 was admitted on 10/22/24 at 4:38 PM and discharged on 10/25/24 at 12:55 PM. Review of P12's history and physical located under the EMR "Notes" tab revealed on 10/22/24 at 6:09 PM P12's chief complaint was pneumonia. Review of P12's EMR indicated there was no documentation of discharge planning for P12.

During an interview on 06/19/25 at 10:56 AM, NAC verified P12's EMR had no documentation that discharge planning had been conducted prior to P12's discharge.

2. Review of P13's EMR "Demographic Header", navigated by NAC, indicated P13 was admitted on 11/19/24 at 6:30 PM and discharged on 11/21/24 at 12:35 PM. with the chief complaint of acute pancreatitis Review of P13's EMR indicated there was no documentation of discharge planning for P13.

During an interview on 06/19/25 at 11:40 AM, NAC verified P13's EMR had no documentation that discharge planning had been conducted prior to P13's discharge.