The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

VIOLATION: Basis and Scope Tag No: A0008
Based on observation, interview, and record review, the facility failed to be primarily engaged with failure to provide 24 hour nursing services rendered or supervised by a registered professional nurse and failure to have a licensed practical nurse or registered professional nurse on duty at all times, failure to conduct utilization review as required, failure to meet the required daily census, and failure to meet the required average length of stay. These findings resulted in the Condition of Participation for Basis and Scope not to be met.


During an observation on 03/08/2019 beginning at 7:45 AM showed two blue signs were observed on the roadside with an "H" on them directing the public to the hospital. One was within 0.5 miles of the hospital and the other was within 0.3 miles of the hospital. In the front of the hospital there was a sign reading "Regional General Hospital Williston". There was a sign to the right of the hospital, while facing the hospital that showed "Emergency Entrance" with an arrow pointing to the right, away from the hospital. The sign showed some of the letters were backwards and others were upside down. The sign was easily observable at a distance of 2,000 feet, and was read as "Emergency Entrance". Following the sign to the back of the hospital showed a sign on a telephone pole that read "EMERGENCY" with a street light above it. Looking toward the left, there was a sign with a red background, showing "EMERGENCY" in white letters. Visible from ten steps away there were two white papers on the emergency room door that could not be read from that distance. After approaching the door the signs were observed to read: EMERGENCY SERVICES TEMPORARILY CLOSED WILL REOPEN SOON. The second sign read Quest Please Use front Entrance Please. RGH Lab. The emergency room was observed to be dark, and there were no patients or staff observed. Entrance into the front of the hospital showed two signs on the door that read: emergency room CLOSED TEMPORARILY SORRY FOR THE INCONVENIENCE. The second sign read SERVICIOS D (not legible due to the paper being torn) EMERGENCIA ESTAN CERRADOS. Below these two signs, there was a sign that read: "OPEN HOURS 8 5". In the lobby there was a sign that read: SERVICES PROVIDED - OUT PATIENT LAB, OUTPATIENT CLINIC, X-RAY, ULTRASOUNDS, CT SCANS, OUT PATIENT PHYSICAL THERAPY. (Photographic Evidence)

On 03/08/2019 at 7:50 AM, after entrance into the facility and introductions, the Risk Manager (RM) stated there were no patients in the hospital, the last patient was on 12/03/2018, and the Emergency Department (ED) remained closed.

During a tour of the facility conducted on 03/08/2019 beginning at 8:00 AM it revealed there were 40 beds in the facility and there were no patients.

During an interview on 03/08/2019 at 8:00 AM with the Housekeeper, she stated: "There is no one here after 5:00 PM. We leave and the door is locked. There are no patients and there has not been a nurse for the last two days. There are no nurses at night because we have no patients."

During an interview on 03/08/2019 at 8:01 AM with the Laboratory Technician he stated they do not run labs for inpatients or the ED (Emergency Department) as there are no patients. The only labs run are for the clinic and outside sources who drop off labs.

During an interview on 03/08/2019 at 8:10 AM with the RM, she stated: "I am the only nurse in the hospital right now. I am a Licensed Practical Nurse (LPN) not a Registered Nurse (RN). I leave at 3:30 PM every day, and then the door is locked. We don't have any patients. The RM stated if there is a patient they will call us." When asked where a patient would come from since there was no ED, she stated: "From a doctor's office. They would call us and we would come in."

During an interview on 03/08/2019 at 8:17 AM with the Advanced Registered Nurse Practitioner (ARNP), she stated she worked Monday to Friday from around 8:15 AM to 5:00 PM and she was an employee of the hospital, but was assigned to the clinic. When asked if the clinic is owned by the hospital, she stated: "As far as I know, they are one in the same."

On 03/08/2019 at 9:28 AM, When the staffing was requested for nursing for the period of 12/16/2018 to present, the RM stated: "We don't have a schedule. There are no nurses' scheduled because there are no patients." When the schedule for the pharmacist and physicians was asked for the period of 03/01/2018 to present, the RM stated: "We have only one pharmacist and we call them if we need them." No additional documentation was provided.

Review of the nursing schedule for the period of 03/01/2018 to 12/15/2018 showed there was a Registered (RN) 24 hours a day except on 07/18/2018 for the night shift, 07/21/2018 for the day shift, 07/22/2018 for the day shift, 07/29/2018 for the night shift, 08/03/2019 for the night shift, 08/04/2018 for the day and night shift, 08/05/2018 for the night shift, 08/10/2018 for the night shift, 08/11/2018 for the night shift, 08/12/2018 for the night shift, 08/17/2018 for the night shift, 08/18/2018 for the day and night shifts, 08/19/2018 for the day and night shifts, 08/20/2018 for the day shift, 08/21/2018 for the day shift, 08/24/2018 for the night shift, 08/25/2018 for the night shift, 09/09/2018 for the night shift, 09/16/2019 for the night shift, 09/24/2018 for the day shift, 09/26/2018 for the night shift, 10/05/2018 for the day shift, 10/13/2019 for the day shift, 10/14/2019 for the night shift, 10/17/2018 for the day shift, 10/18/2018 for the day shift, 10/21/2018 for the day shift, and 10/28/2018 for the night shift. There were no nurses scheduled since 12/15/2018.

Review of the Average Daily Census for the last 12 months for 03/01/2018 to 03/01/2019 was 0.1150. There was a total of 43 patients for this period of time.

Review of the Average Length of Stay for the period of 03/01/2018 to 03/01/2019 showed 3.0476. There were 128 patient days with 42 discharges for this period of time.

Review of the Utilization Review documentation showed a utilization review was not conducted for 10/2018 through 12/2018.

During an interview on 03/08/2019 at 1:44 PM with the CEO (Chief Executive Officer), he stated: "There have been no nurses or physicians scheduled since 12/15/2018. There is a pharmacy director that comes twice a week and then is on call 24/7. There is a pharmacy tech that is here twice a week at a minimum. She lives here in the city and she will come here when we call. The pharmacy director is here Tuesday and Thursday afternoons. I don't have it written on a schedule because we know that is the day the pharmacy director comes to the hospital." When a request was made to review the physician schedule for the period of 03/01/2018 to 12/15/2018, The CEO stated: "The physician is not really scheduled. He would come in and make rounds. When The Average Daily Census for the period of 03/01/2018 to 03/01/2019 was reviewed with the CEO, he confirmed the total patients for the period were 43. When The Average Length of Stay for the period of 03/01/2018 to 03/01/2019 was reviewed with the CEO, he confirmed the total patient days were 128 and there were 42 discharges. When asked regarding the nursing schedule from 12/15/2018 to present, the CEO stated: "If we scheduled nurses we would have to pay them." When asked regarding the Utilization Review not having been conducted since 10/2018, the CEO stated: "We have only one physician. He is the Medical Director. He is not able to review himself, so what are we supposed to do in that kind of situation?"