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Based on policy and procedure review and interview, it was determined that the facility failed to have an eligible and/or board-certified pathologist to oversee the laboratory and a laboratory director per Arkansas State Regulations. The failed practice did not ensure that the laboratory services were being performed under a board-certified pathologist. The failed practice had the likelihood to affect all patients presenting to the hospital. Findings follow:

A. Review of Rules for Hospitals and Related Institutions in Arkansas, Section 19 B 2, showed that "The laboratory shall be under the oversight of a pathologist who is board certified or eligible. A pathologist who is not based at the hospital shall make at least a monthly visit and submit a monthly written report to the Hospital Administrator."

B. In an interview with Chief Executive Officer on 11/22/2024 at 8:21 AM, she stated that "on 11/21/2024, the previous Pathology group had terminated their contract with the hospital. We are in the process of making an offer to another pathology group. As of today, we do not have a pathology group or a laboratory director for the laboratory."

Based on review of personnel files and interviews, it was determined that the facility failed to provide basic laboratory services 24-hours a day based on nationally recognized standards of care. The failed practice did not ensure a timely diagnosis of patients being seen in the hospital. Without a diagnosis for treatment, the patient receiving emergent services had the likelihood for a delayed care. Findings follow:

A.Review of Medical Technologist/Medical Laboratory Technician Competency Assessment on 11/22/2024 at 8:25 AM, showed the only employee in the laboratory was a Medical Laboratory Technician who was not competent in the following:
1) Selecting correct tube order.
2) Processing/storing specimens correctly (including spencimens sent to reference laboratory.
3) Performing waived tests according to package insert instructions.
4) Performs non waived kit testing.
5) Understands when to to hold sample for culture.
6) Understands when to hold sample for culture.

B. Review of Clinical Laboratory Medical Technician job description dated 05/06/2021, stated the Job summary as "Under the supervision of the Eureka Springs Hospital Laboratory Director and the Laboratory Supervisor, the technician is responsible for the performance of testing and operation of the clinical laboratory services for Eureka Springs Hospital. The Medical Technician is capable of working without direct supervision and he/she adheres to all established policies of the hospital. The technician sees that all results are performed and reported accurately and in a timely manner." The duties of a Medical Technician as the following:
1) Participates in and directs daily specimien collection and performs requested analyses.
2) Confers regularly withthe Laboratory Supervisor and heeps he/she informed of any problems with equipment, abnormal tests , and/or quality control problems.

C. In an interview with the Interim Chief Executive Officer on 11/22/2024 at 8:26 AM, she stated, "as of 11/21/2024 at 7:30 AM, the laboratory medical technician and the Registered Nurses in house are doing laboratory blood draws and a courier service is driving them to Berryville Hospital." The surveyor asked what would happen if a patient who needed emergent care, that could only be diagnosed through laboratory results, walked in and needed services. She stated, "the laboratory blood work results would not be done in a timely manner."

D. In an interview with Registered Nurse #1 on 11/22/2024 at 8:10 am, he stated, "We are drawing laboratory draws on patients and then couriering them to Berryville Hospital because we do not have anyone in the laboratory qualified to run laboratory tests. We have been on trauma diversion since 11/21/2024 at 7:45 am." The surveyor asked the nurse what they would do if someone walked in having a possible heart attack, he said, "we would draw a troponin laboratory blood test, however, by the time the results returned from Berryville Hospital, the patient could die."

Based on an interview, it was determined the facility failed to ensure a Registered Nurse, who is responsible for the operation of the services to include determining the types and numbers of nursing personnel to provide nursing care, was directing the nursing services. The failed practice did not ensure a Registered Nurse supervised the care provided in the facility. The failed practice had the likelihood of affecting all patients receiving care in the facilty. See O-604 for details.

Based on an interview, it was determined the facility failed to ensure a Registered Nurse, who is responsible for the operation of the services to include determining the types and numbers of nursing personnel to provide nursing care, was directing the nursing services. The failed practice did not ensure a Registered Nurse supervised the care provided in the facility. The failed practice had the likelihood of affecting all patients receiving care in the facilty. Findings follow:

In an interview with the Interim Chief Executive Officer on 11/22/2024 at 9:30 AM, she confirmed that there was not a Registered Nurse directing nursing services. She stated, "I am making out the schedules for the staff." The Interim Chief Executive Officer confirmed she was not a Registered Nurse.