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.

Based on personnel file review and interview, the Director of Nursing (DON) failed to ensure all nursing personnel received a performance evaluations at least once a year for 3 of 3 Registered Nurses (RN #1,#2 and #3) and 2 of 2 Licensed Practical Nurses (LPN #1 and #2) nursing personnel files reviewed and for 18 RNs and 16 LPNs who were listed on the current up to date roster presented to this surveyor by the Chief Executive Officer (CEO).

The findings included:

Review of the personnel file for RN #1 revealed a hire date of 5/20/2008. The last performance evaluation was completed on May 2017. The last competency evaluation was completed 5/19/2016.

Review of the personnel file for RN #2 revealed a hire date of 9/4/2018. The last performance evaluation was completed on 9/4/2018. The last competency evaluation was completed 10/3/2018.

Review of the personnel file for RN #3 revealed a hire date of 5/31/2016. The last performance evaluation was completed on 5/31/2017. The last competency evaluation was completed 2017.

Review of the personnel file for LPN #2 revealed a hire date of 6/30 2011. There is no documentation in the file of a performance evaluation or a competency evaluation.

In an interview the CEO stated there had not been an annual evaluation or competencies completed of any nursing staff since 2017. The CEO verified there were a total of 18 RNs and 16 LPNs currently working at the hospital.
Based on observation and interview, the hospital failed to ensure a Registered Nurse (RN) was immediately available to provide supervision for the nursing services being provided by the licensed practical nurse (LPN) on all hospital units during 1 of 1 (3/16/2020) days of observation.

The findings included:

Observations on 3/16/2020 at 9:40 AM revealed RN #1 was working and providing direct care in the emergency room (ER). The RN was also assigned to provide supervision of the LPN who was providing care on the nursing units The inpatient census for the medical floor was two (2) and there were 2 patients in the ER at the time of the observation. There was 1 Licensed Practical Nurse providing care to the patients on the medical floor.

In an interview on 3/16/2020 at 10:05 AM, RN #1 stated she was providing direct care to the patients in the ER and was providing supervision on the nursing units.

The hospital failed to ensure the availability of the RN to provide supervision to the LPN and nursing services being delivered on the nursing units.
Based on observation and interview, the hospital failed to ensure it maintained and had available adequate laboratory services to meet the needs of its patients.

The findings included

In an interview in the laboratory (lab) on 3/16/2020 at 11:36 AM, the Interim Lab supervisor stated he had started 3 weeks ago. He stated it was very difficult to get lab supplies, and the lab was short of or did not have the following:
(a). Reagents to perform Brain Natriuretic Peptide (BNP - this test assists physicians with diagnosis and treatment for Congestive Heart Failure). The Interim Lab supervisor stated the test were sent by a driver to Hospital #2 for processing and it was getting harder to find someone to drive them to Hospital #2.
(b). The lab only had 2 drug screen kits.
(c). The lab did not have any Quality Controls to do C-reactive protein (CRP - is a blood test marker for inflammation in the body).
(d). The lab only had a 2 week supply of cardiac quality controls.
(e). The lab only had 17 cartridges to do Arterial Blood Gases (ABG - ABG testing measure oxygen and carbon dioxide levels in the blood. The Interim Lab supervisor stated ABGs required the use of 2 cartridges for each test and, "...As of Friday I was told I would have to go through the County Commissioners and Attorney General to buy a new ABG machine. After we use the 17 cartridges we will not be able to use the machine we have, it is obsolete and we will not be able to use it.."
(f). The lab did not have any Micro Albumin (Micro Albumin is a test used to detect early signs of kidney damage).
reagents or quality controls. He stated these tests were sent to Hospital #2's lab.
(g). The lab had only 12 units of blood on hand.
(h). The lab had enough D-Dimer (D-Dimer is a test for blood clots) for one week.

The Interim Lab supervisor stated the Testing Institute that provides test samples for use to test for verification was being held up due to non-payment. He stated they are holding proficiency test until payment is received. He stated they had a contract with Hospital #2 and stat (immediate) labs were picked up at 4:00 PM and results were obtained later that night.
The Interim Lab supervisor was unable to provide the contract.
The Interim Lab supervisor stated the CEO was aware of all the problems with lab supplies because he would submit a weekly report to the CEO.

In an interview on 3/17/2020 at 12:44 PM, the CEO stated she was not aware of all the shortages. The CEO was unable to provide a contract agreement with labs to provide lab services for the hospital.

Based on record review and interview, the hospital failed to ensure it had appropriate professional and non-professional personnel available at each location where outpatient services are offered and provided continuity of care to its patients for 1 of 2 (Patient #1) receiving outpatient services.

The findings included:

Physician orders were faxed to the hospital on [DATE] at 10:11 AM for Patient #1 to receive an outpatient Chest X-ray with rib detail related to rib pain.

In a telephone interview on 3/17/2020 at 8:49 AM, Patient #1 stated, "...I walked to the front door, where the outpatient door is. There was a sign on the door that said to ring the bell for service. There wasn't anyone at the desk and the bell was inside the window. I waited a bit. I could hear people talking in the back. I finally reached around the window and rang the bell. Someone came up from the hallway and asked if I needed help. I told her I was here for an x-ray. She told me to go to outpatient. I told her there was no one there. I know my way around the hospital so I went to X-ray. The lady there told me to go to the ER (emergency room ) and get checked in. I was sent by the doctor to get an x-ray but didn't have the order with me. It was faxed by the clinic. The hospital said they didn't have an order. It didn't take 10 minutes to get the X-ray once I got checked in, but it took about an hour or an hour and a half to find someone to check me in. I was in pain and didn't feel like I should have to walk all over the hospital.

In an interview on 3/17/2020 at 10:43 AM, the Outpatient registration clerk verified she was working on 2/25/2020. She stated she had left to pick up a sick child at school and had placed a sign on the door for patients to go to the nurse station where ER registration is located. She stated when no one is at the Outpatient registration desk a sign is placed on the door redirecting patients to ER registration so they can check in.

In an interview on 3/17/2020 at 10:55 AM, the ER registration clerk stated, "... on 2/25/2020, the Outpatient registration clerk had told me she needed to leave and had brought all the out -patient orders for me to check in the patients..." The ER clerk stated she remembered checking Patient #1 in and that he was upset. His orders were not there and she called the physician office to have them faxed them over. She stated the fax machine in the ER registration office was messed up and was being worked on while Patient #1 was sitting in front of her. She stated she finally received the orders. The ER clerk stated, "...He (Patient #1) was upset because of the wait, he said he went to outpatient and no one was there then went to radiology and they told him to go to outpatient where he sat for 5 or 10 minutes, then he went to the front office and they told him to come and register with me. He told me he had been here at least 45 minutes and went to four (4) locations and he was upset about this. I checked him in at 10:51 AM and he left at 11:17 AM. I don't remember what time the fax was re-sent by the clinic..."