HospitalInspections.org

Based on review of a facility list of scope of services, review of a facility communication, observations, and interview, the facility failed to ensure Laboratory scope of services were maintained 24 hours a day 7 days per week to meet the needs of any future patient of the hospital.

The findings included:

Review of a list of scope of services provided by the facility on 6/12/19 revealed the facility provided laboratory services including complete blood counts (CBC) and general chemistry (laboratory blood tests to determine a patient's general health).

Review of a facility communication (e-mail) from the Laboratory Director to the laboratory supplier dated 5/21/19 at 3:55 PM revealed "...is the [named Hematology reagent/used to perform laboratory tests] a standing order? These expire in mid-June so we will need them in the next week or so...there is a credit hold per our purchasing manager. Please let me know how much has to be paid on this so I can get the [named controls]. I will pass along to accounts payable so they can send a payment... "

Review of a facility communication (e-mail) from the laboratory supplier to the Laboratory Director dated 5/23/19 at 3:43 PM "... I believe there may a credit hold so I will have to check but if there is a credit hold I cannot override the hold until invoices are resolved..."

Observation of the Laboratory on 6/12/19 at 11:30 AM revealed the Hematology Analyzer (machine used to perform laboratory tests) was not in service. Further observation revealed the Hematology Analyzer was used to perform laboratory blood tests.

Observation of the Laboratory on 6/13/19 at 10:30 AM revealed the Hematology Analyzer was not in service and the laboratory tests were sent to another acute care hospital to be performed.

Interview with Medical Laboratory Technician (MLT) #1 and Medical Technologist (MT) #1 on 6/12/19 at 11:30 AM, in the Laboratory, confirmed the Hematology Analyzer was not available for use and the facility could not perform CBCs. Further interview revealed "...we ran out of reagent and cannot perform the quality controls. The reagent expired on 6/10/19...we are having to send the Stat [needed immediately] labs out to [named sister acute care facility/located approximately 40 miles away] by courier...they perform the test and fax them to us...outpatient labs are held until we get a full batch to send and they usually resulted the next day..."

Interview with the Materials Management Supervisor on 6/12/19 at 2:05 PM, in the Materials Management Office, revealed the Laboratory Diagnostic reagents were requested to be ordered on 5/23/19 and 6/10/19 and "...the [account] is on a credit hold by the company and we cannot get the supplies related to the hold...it has been on hold for 1 month...I spoke with [named vendor] on 5/23/19 and ordered the supplies. I was given a confirmation number but we have not received the supplies related to a credit hold. I did order them again on 6/10/19 but we cannot get the supplies. The lab had told me they cannot perform the diagnostic test without the quality controls for the machine..."

Interview with the Director of Revenue Cycle on 6/12/19 at 3:50 PM, in the conference room, revealed "...we are not sure of the dollar amount of the credit hold..."

Interview with Emergency Department (ED) Physician #1 on 6/13/19 at 10:25 AM, in the ED conference room, confirmed the facility was unable to perform CBC's at this time and the blood tests were sent to (named sister facility) to be done. Further interview revealed "...if we need a STAT CBC they are sending them by courier..."

Interview with MLT #2 on 6/13/19 at 10:50 AM, in the Laboratory, confirmed "...we are waiting on the quality control reagents for the Hematology Analyzer. The reagents should have been delivered on Tuesday [6/11/19] but we have not received them. We are sending the labs to [named sister facility] by courier from the ED and the outpatient tests are sent by batch when we accumulate enough of the specimens to send..."