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Based on review of facility policy, review of facility Advisory Board Meeting minutes, review of facility accounts payable vendor aging reports, medical record review, and interview the facility failed to ensure the availability of radiology services (computed tomography) 24 hours per day for 98 consecutive days during the period of 12/17/2020-3/25/2021.

The findings included:

The hospital CT (Computed Tomography) scanner used to perform diagnostic studies to allow physicians to diagnose and treat patients was not in operation from 12/17/2020 to 3/25/2021. Patients requring a CT scan had to be discharged to another hospital for care, delaying diagnosis and treatment, and placing patients at risk.

Refer to A-0529 for additional findings.

Based on review of facility policy, review of payroll time punches, medical record review, and interviews, the facility failed to provide emergency laboratory services 24 hours per day for 23 shifts during the period of 2/1/2021-3/25/2021.

The findings include:

The hospitals laboratory services used to perform diagnostic studies to allow physicians to diagnose and treat patients was not available for 23 shifts from 2/1/2021-3/25/2021. Patients requiring laboratory services had to be discharged to another hospital for care, delaying diagnosis and treatment, and placing patients at risk.

Refer A-0583 for additional findings.

Based on review of facility documentation, review of competencies, and interviews, the facility failed to ensure competency of Emergency Department (ED) nursing staff related to the use of bedside laboratory equipment for 14 ED nursing staff of 22 ED nursing staff reviewed.

The findings include:

Review of facility documentation of a letter from the Rules Governing Medical Laboratories and Medical Laboratory Personnel in Tennessee dated 10/28/2020, showed the facility had been granted exemptions which "...permitted Registered Nurses [RN], Licensed Practical Nurses [LPN], Registered Respiratory Therapist, and Certified Respiratory Therapist in the Emergency Department, Med/Surg [Medical/Surgical] Unit, and Respiratory department to perform and report Arterial Blood Gases [ABG]...Lactate Testing utilizing [named bedside laboratory equipment]...and methodology...perform and report Troponin utilizing the [named bedside laboratory equipment]...and methodology...perform and report Sodium, Potassium, Chloride, BUN [blood urea nitrogen], Creatinine, Lactate [chem 8]...and Hematocrit testing utilizing the [named bedside laboratory equipment]...and methodology..."

Review of the competency checklist and training for the operation of the [bedside laboratory equipment] showed no documentation of training for the use of the bedside laboratory equipment for RN #1, RN #2, RN #3, RN #4, RN #5, RN #6, RN #7, RN #8, LPN #1, LPN #2, LPN #3, LPN #4, LPN #5, and LPN #6.

During an interview on 3/25/2021 at 11:15 AM, in the conference room, the ED Nurse Manager stated the ED staff used the bedside laboratory equipment for Chem 8, Troponins, and ABG's. Further interview confirmed there were 8 RN's and 6 LPN's who did not have a documented competency for the use of the bedside laboratory equipment.

Based on review of Advisory Board Meeting minutes, review of laboratory time punches, medical record review, and interview the facility failed to ensure a true and complete medical record was available for 1 transferred patient (#1) of 6 transferred patients reviewed.

The findings include:

Review of the facility Advisory Board Meeting minutes dated 1/25/2021 and 3/22/2021 showed the CT scanner was "...down..."

Review of the payroll time punches for 2/1/2021-3/25/2021 for the Laboratory showed there was no day shift or night shift coverage (24 hour period) on 3/18/2021.

Medical record review showed Patient #1 presented to the Emergency Department (ED) on 3/18/2021 and was diagnosed with Acute Viral Syndrome with Acute Febrile Illness/Acute Viral Meningitis. According to the ED record, the patient had a CT of the head and a CBC (complete blood count-test) performed, however, CT scan and CBC results were not found in the medical record. Patient #1 was transferred to another acute care hospital on 3/18/2021.

During an interview on 3/25/2021 at 1:30 PM, in the conference room, the Radiology Director stated the CT scanner was out of service beginning 12/17/2020. As of 3/25/2021 (98 days), the CT scanner had not been repaired and the facility was unable to perform CT scans. The Radiology Director stated all patients in need of a CT scan were "...sent to another hospital..." for those services.

During an interview on 3/25/2021 at 11:40 AM, the Chief Executive Officer confirmed the facility did not have the ability to perform CBC's when the laboratory was not staffed.

During an interview on 3/25/2021 at 4:00 PM, in the conference room, the ED Manager confirmed a CT scan and CBC were not performed for Patient #1.

Based on review of facility policy, review of facility Advisory Board Meeting minutes, review of facility accounts payable (AP) vendor aging reports, medical record review, and interview, the facility failed to ensure the availability of radiology services (computed tomography) 24 hours per day during the period of 12/17/2020-3/25/2021.

The findings include:

Review of the facility policy "Scope of Services" revised 8/2019 showed "...Radiology. Staffed with a minimum of 1 licensed technologist 24/7/365 [24 hours per day/7 days per week/365 days per year]...Services include: Radiography...Computed Tomography [CT]...Computed Tomography with contrast..."

Review of the facility Advisory Board Meeting minutes dated 1/25/2021 and 3/22/2021 showed the CT scanner was "...down..."

Review of the facility AP Vendor Aging Report dated 3/25/2021 showed the facility owed the company contracted for CT scanner service/repairs $73,944.77 and was past due on payment over 120 days.

Medical record review showed Patient #1 presented to the Emergency Department (ED) on 3/18/2021 and was diagnosed with Acute Viral Syndrome with Acute Febrile Illness/Acute Viral Meningitis. According to the ED record, the patient had a CT of the head, however, CT scan results were not found in the medical record. Patient #1 was transferred to another acute care hospital on 3/18/2021.

During an interview on 3/25/2021 at 1:30 PM, in the conference room, the Radiology Director stated the CT scanner was out of service on 12/17/2020, was back in service on 1/19/2021 for approximately 5 hours, then was out of service again the same evening. As of 3/25/2021 (98 days), the CT scanner had not been repaired and the facility was unable to perform CT scans. The Radiology Director stated all patients in need of a CT scan were "....sent to another hospital..." for those services.

During an interview on 3/25/2021 at 2:40 PM, in the Chief Executive Officer's (CEO) office, the CEO confirmed the CT scanner had been out of service since 12/17/2020 (98 days) and he did not know when the scanner would be repaired. The CEO confirmed the CT scanner had not been repaired due to nonpayment to the contracted service company.

During an interview on 3/25/2021 at 4:00 PM, in the conference room, the ED Manager confirmed CT scans were not completed for Patient #1.

Based on review of facility policy, review of payroll time punches, medical record review, and interviews, the facility failed to provide emergency laboratory services 24 hours per day for 1 Emergency Department (ED) of 1 ED observed during the period of 2/1/2021-3/25//2021.

The findings include:

Review of facility policy "Scope of Services" approved 8/29/2019 showed "...provision of services...Laboratory...staffed with a minimum of 1 technologist 24/7/365 [24 hours per day/7 days per week/365 days per year]...inpatient and outpatient services are provided..."

Review of the payroll time punches for 2/1/2021-3/25/2021 for the Laboratory showed the following staff coverage:
A. No night shift coverage (6:00 PM-6:00 AM) on 2/4/2021, 2/16/2021, 2/17/2021, 3/17/2021, and 3/24/2021 (5 shifts)
B. No day shift coverage (6:00 AM-6:00 PM) on 2/12/2021, 2/18/2021, 2/20/2021, 2/21/2021, 2/26/2021, 2/27/2021, 2/28/2021, 3/5/2021, 3/7/2021, 3/13/2021, 3/20/2021, and 3/21/2021 (12 shifts)
C. No day shift or night shift coverage (24 hour period) on 2/15/2021, 3/14/2021, and 3/18/2021 (3 24-hour shifts)

Medical record review showed Patient #1 presented to the ED on 3/18/2021 and was diagnosed with Acute Viral Syndrome with Acute Febrile Illness/Acute Viral Meningitis. According to the ED record, the patient had a CBC, however, the CBC result was not found in the medical record. Patient #1 was transferred to another acute care hospital on 3/18/2021.

During an interview on 3/25/2021 at 11:40 AM, in the conference room, the Chief Executive Officer stated the laboratory supervisor resigned 2/21/2021 and a laboratory technician contract had expired on 2/8/2021. There was no laboratory staff coverage for 23 shifts during the period of 2/1/2021-3/25//2021.

During an interview on 3/25/2021 at 2:30 PM, in the conference room, the Chief Nursing Officer confirmed the laboratory was not staffed 24/7/365 as stated in the facility policy for 23 shifts during the period of 2/1/2021-3/25//2021.