HospitalInspections.org

Based on observation and staff interviews, the facility failed to meet the standards for licensing established by the state to have an operational low voltage nurse call system with an annunciator at the nurses' work area for four (4) of (4) patient exam rooms in the Emergency Department (ED); Emergency Room #1, #2, #3 and Trauma/Obstetric (OB) Room.

Findings Include:

During a tour of the Emergency Department (ED) on 12/04/2024 at 11:38 a.m. with Registered Nurse (RN) RN #1, observation and testing revealed four (4) of the four (4) ED patient exam rooms did not have a functional electric nurse call system, ER #1, ER #2, ER #3, Trauma/OB room.

During an interview with RN #1 on 12/04/2024 at 11:38 a.m., it was confirmed the electric nurse call system is not functional. RN #1 further confirmed the nonfunctional call light was not working this morning on arrival to the morning shift.

During an interview with RN #1 on 12/04/2024 at 11:48 a.m., it was confirmed the staff report maintenance issues to the Maintenance Assistant if repairs are needed.

During an interview with the Administrator on 12/04/2024 at 11:55 a.m., it was confirmed the electric nurse call system in the ED is not functional. The Administrator further confirmed a work order has not been received or a replacement unit has not been ordered. The Administrator confirmed the maintenance assistant will be notified.

During an interview with RN #1 on 12/04/2024 at 3:35 p.m., the electric nurse call system worked for a few minutes after the maintenance assistant replaced the batteries, but the call system stopped working shortly after the batteries were replaced.
During an interview with the DON on 12/05/2024 at 9:40 a.m., it was confirmed when staff identify broken equipment or anything that needs repairs, staff are to fill out a maintenance request and send the request to the maintenance department.

During an interview with the Maintenance Assistant on 12/05/2024 at 11:04 a.m., it was confirmed a work order is not available for the nonfunctioning electric call system in the ED. It was further confirmed the maintenance assistant was notified yesterday of the electric nurse call system not working in the ED, and the batteries for the desktop electric nurse call system were replaced. The maintenance assistant confirmed the electric nurse call system worked for a little while after the batteries were replaced and then quit working again. The maintenance assistant further confirmed there is currently no plan at this time to replace the electric nurse call system.

During an interview with the DON on 12/05/2024 at 1:42 p.m., it was confirmed the facility does not have a policy for the electric nurse call system, or a policy for submitting a work order to maintenance for repairs.

During exit conference on 12/05/2024 at 4:00 p.m. with the Administrator and the Director of Nursing (DON), survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview and review of the facility's attestation for conversion to Rural Emergency Hospital (REH) sent to CMS with their CMS-855 application to convert from a Critical Access Hospital (CAH) to a Rural Emergency Hospital (REH) dated 02/07/2024, ref# 3240240201, Provider # 251329, (conversion request documentation in CMS), the facility failed to ensure the development, approval, or adoption of required policies and procedures: a description of the services it furnishes including those furnished through agreement or arrangement; policies and procedures for emergency medical services; policies for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral; the maintenance of health care records; and procedures for the periodic review and evaluation of the services furnished; and policies and procedures that address the post-acute care needs of patients receiving services in the REH for three (3) of three (3) days of survey.

Findings Include:

During the Entrance Conference on 12/03/2024 beginning at 1:00 p.m. with the Director of Nursing (DON) conducted by the team leader, a request was made for the facility's policy and procedures for services it furnishes to include those furnished through agreement or arrangement; polices for the medical management of health problems, consultation or referral, maintenance of health care records, and procedures for the periodic review and evaluation of the services provided and discharge planning, and the facility's attestation for conversion to Rural Emergency Hospital (REH). No documented evidence of requested policies and procedures presented for review.

During an interview with the Director of Nursing (DON) on 12/05/2024 at 1:42 p.m., it was confirmed the last review of the facility's policies and procedures was 09/14/2022. It was further confirmed the policies and procedures are to be reviewed annually. The DON confirmed there are no policies available for review for the Rural Emergency Hospital (REH) at this time.

Review of the facility document, "Greene County Hospital, Summary of Conversion Plan," sent to CMS with their CMS-855 application to convert from a Critical Access Hospital (CAH) to a Rural Emergency Hospital (REH) dated 02/07/2024, ref# 3240240201, Provider # 251329, (conversion request documentation in CMS), " ...Attestation: I understand that as an REH, the facility must meet all Conditions of Participation (CoP) in 42 CFR, Part 485 ...including the following: ...485.514 CoP: Provision of Services ...currently meets and will continue to meet all requirements for Rural Emergency Hospitals set forth in Subpart E of 42 CFR, Part 485 and other applicable Federal law and regulation ...", signed by the Administrator.

During exit conference on 12/05/2024 at 4:00 p.m. with the Administrator and the Director of Nursing (DON), survey findings were discussed, and no further documentation was submitted for review.