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Based on review of the Rules and Regulations, monthly meeting reports for the Governing Body, review of weekly manager's meeting notes, and staff interviews, it was determined the Governing Body failed to ensure compliance with the Conditions of Participation was maintained and that quality patient care was provided in a safe environment.

These deficient practices had the potential to negatively affect all patients served by this facility.

Findings:

Refer to Tags A 0091, A 0392, A 0454. A 0458, A 0467, A 0583, A 1103, and A 1110.

Based on the review of nursing schedules, nurse staffing policy, and hospital diversion logs, it was determined the facility failed to ensure:

1. Staffing was adequate to provide safe care to all patients admitted to the facility for treatment.

2. The hospital could treat all patients seeking emergency treatment and not be diverted elsewhere due to lack of staffing.

This deficient practice had the potential to negatively affect all patients who presented to the facility for treatment.

Findings:

Refer to Tag A 0392.

Based on review of the laboratory (lab) calibration logs, Emergency Department (ED) diversion logs, and staff interviews, it was determined the facility failed to ensure lab services were available to meet the needs of the patients, resulting in patients:

1. Being denied admission for treatment to the detox program.

2. Diverted from seeking emergency treatment at the facility.

This deficient practice had the potential to negatively affect all patients served by this facility.

Findings:

Refer to Tag A 0583.

Based on the review of nursing schedules, nurse staffing policy, diversion policy, and hospital diversion logs, it was determined the facility failed to ensure:

1. Staffing was adequate to provide safe care for patients presenting to the Emergency Department (ED) for treatment.

2. Laboratory and radiology testing was available for patients presenting to the ED.

3. Diversion Logs indicated an end time for the eight days the ED was on diversion in May 2025 and June 2025.

These deficient practices had the potential to negatively affect all patients who presented to the ED for treatment.

Findings:

Refer to Tag A 1103 and 1110.

Based on review of the monthly meeting reports for the Governing Body, review of weekly manager's meeting notes, and staff interviews, it was determined the Governing Body failed to ensure emergency services were available 24/7.

This deficient practice had the potential to negatively affect all patients served by this facility.

Findings include:

A review of the Governing Body Meeting Minutes revealed the following documents:

Patient Care/Infection Control/Quality Control For November 2024 Monthly Report

Patient Care/Infection Control/Quality Control For December 2024 Monthly Report

Review of the November report revealed the following documentation: "Positive Viral Diseases reported for Emergency Department (ED) patients in November: 0 Covid, 0 influenza (flu), 0 respiratory syncytial virus (RSV), and 0 streptococcus (Strep). These counts are low due to a laboratory (lab) shortage in supplies."

Review of the December report revealed the following documentation: "Viral Diseases reported for ED patients in December: 9 Covid, 0 flu, 10 RSV, and 0 Strep. There were no flu or Strep tests done in December because the lab was out of tests."

Review of the lab notes for the weekly manager's meeting (which includes all department heads and Employee Identifier (EI) # 3, Chief Executive Officer (CEO)) revealed the following documentation on the Weekly Report form:

Dated 5/5/25 to 6/2/25: "We are currently out of flu and RSV testing, calcium, sodium, and Hemoglobin A1C testing."

6/2/25 to 6/9/25: "We are currently out of flu, Strep, and RSV testing, calcium, glucose, potassium, total protein, Verifier I and Verifier II controls, sodium, and Hemoglobin A1C testing. We are low on Sample supply tray tips (17). Once the sample supply tray tips are out, we will no longer be able to perform testing on the Chemistry analyzer. We are also low on alcohol, chloride, carbon dioxide blood testing (ECO2), cardiac testing, and B-type natriuretic peptide test (BNP)."

6/9/25 to 6/16/25: "We are currently in a lab crisis. Labs that can't be ordered are as followed: albumin, alcohol, alkaline phosphatase, alanine aminotransferase test (ALT), amylase, aspartate aminotransferase (AST), blood urea, blood cultures, calcium, cholesterol, creatine kinase (CK), chloride, creatinine, digoxin, high-density lipoprotein test, ECO2, glucose, potassium, lipase, magnesium, sodium, phosphorous, dilantin, total bilirubin, total protein, triglycerides, blood urea nitrogen (BUN), uric acid, basic and complete metabolic profiles, lipids, liver function, and renal profile. We are currently holding the one box of flu and RSV."

6/16/25 to 6/23/25: "We received most of the Fisher supplies. We are currently still out of Digoxin until other supplies arrive (it is on backorder). We are currently low on creatine kinase MB, troponin, and BNP. Controls on the Beckman will expire on 7/5/25. We are currently still holding the box of flu and Strep."

According to EI # 2, Lab Director, supplies were not ordered in May because they did not have the means to pay for them.

A copy of requisition requests for lab supplies revealed four requisitions signed by EI # 2 and dated 6/19/25.

An interview on 6/25/25 at 1:30 PM with EI # 2 revealed on 6/12/25 the lab ran out of tips for the Vitros XT 3400 machine and were unable to run labs on that machine from 6/13/25 until 6/24/25 when supplies were delivered.

The Governing Body and hospital leadership failed to act and ensure services for patient care was available 24/7 after being made aware, since November 2024, of the inability to perform critical laboratory tests due to a lack of supplies.

Based on the review of policies, Staffing Plan for Hospital Nursing Services, nurse staffing schedules, diversion logs, patient census logs, and staff interview, it was determined the facility failed to ensure staffing was adequate to meet the needs of the patients admitted and those seeking emergency treatment.

This deficient practice had the potential to negatively affect all patients presenting to this facility for treatment.

Findings include:

Policy Name: Nursing Staffing

Department: All Hospital Units

Policy Number: none

Revision Date: 07/2023

Purpose: To ensure that appropriate nursing staff levels are maintained to deliver safe, high-quality care in a rural hospital setting, considering unique challenges such as limited workforce, financial constraints, and geographic isolation.

Policy Statement: This hospital commits to staffing nursing units with an appropriate number and mix of qualified nursing personnel based on patient acuity, census, available resources, and regulatory requirements...

Staffing Ratios:

Medical/Surgical Unit: 1 Registered Nurse (RN)/Licensed Practical Nurse (LPN): 4 to 6 patients (adjusted based on acuity)

Detox: 1 RN or LPN per shift, with Certified Nursing Assistant (CNA) support

Emergency Department (ED): Minimum of 1 RN and 1 additional clinical staff 24/7...


Policy Name: Diversion Status

Department: Emergency Department

Policy Number: none

Revision Date: 07/2023

This policy outlines the procedure for declaring, maintaining, and terminating diversion status when the ED is overwhelmed or unable to safely accept additional patients.

Purpose: To establish a standardized protocol for initiating, managing, and terminating ED diversion status when patient volume and/or acuity exceeds the capacity of the ED to provide safe care.

Scope: This policy applies to all staff within the ED, hospital administration, nursing supervisors, Emergency Medical Services (EMS) liaisons, and other departments involved in ED operations...

A diversion log must be started and maintained by the ED Charge Nurse.

1. Review of the Staffing Plan for Hospital Nursing Services provided to the surveyor by Employee Identifier (EI) # 1, Chief Nursing Officer (CNO) on 6/25/25 revealed the following statement: "The clinical staff works all three units each shift: (Med Surg; ED; and Detox)."

Review of the staffing schedule for May 2025 and June 2025 revealed on 5/21/25, 5/28/25, and 6/16/25, there was one RN and one CNA scheduled for dayshift and the same on nightshift and not one RN for Detox and one RN for the ED as directed in the facility policy.

On 6/17/25, there was one CNA working nightshift and one RN working 11:00 PM to 7:00 AM and not one RN for Detox and one RN for the ED as directed in the facility policy

Review of the patient census for 5/21/25 revealed five patients were seen in the ED and there were three patients on the Self Recovery unit.

Review of the patient census for 5/28/25 revealed eleven patients were seen in the ED and there were three patients on the Self Recovery unit.

Review of the patient census for 6/16/25 revealed eight patients were seen in the ED and there were three patients on the Self Recovery unit.

Review of the patient census for 6/17/25 revealed five patients were seen in the ED and there were two patients on the Self Recovery unit.

An interview conducted on June 26 at 3:00 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, confirmed the facility was not following their own policy for staffing the hospital.

2. Review of the Hospital Diversion Logs for May 2025 and June 2025 revealed the hospital was on diversion on the following dates due to a nursing shortage: 5/21/25, 5/28/25, 6/12/25, 6/16/25, 6/17/25, and 6/19/25.

An interview was conducted on 6/26/25 at 4:42 PM with EI # 4, ED Medical Director, who confirmed the ED physician on call is the one who makes the decision to go on diversion.

The facility failed to ensure staff was available to meet the needs of both patients admitted to the facility and those seeking emergency treatment.

Based on medical record (MR) review, review of the Rules and Regulations, and interview with staff, it was determined the facility failed to ensure the ordering physician dated, timed, and/or authenticated all orders.

This deficient practice affected two of three inpatient MRs reviewed, including Patient Identifier (PI) # 8 and PI # 10, and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Rules and Regulations Medical Staff Greene County Hospital
...Medical Records
...9. All clinical entries in the patient's medical record shall be accurately timed, dated, and authenticated...

1. PI # 8 was admitted to the facility on 5/17/25 with a diagnosis of medical detox. Review of the MR revealed the admission orders from 5/17/25 were not signed, dated, or timed by the admitting physician.

An interview conducted on 6/26/25 at 2:43 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, confirmed the orders were not properly authenticated with a physician signature, date, and time.

2. PI # 10 was admitted to the facility on 6/13/25 with a diagnosis of multisubstance drug abuse. Review of the MR revealed the admission orders from 6/13/25 were not dated or timed by the admitting physician.

An interview conducted on 6/26/25 at 2:39 PM with EI # 1 confirmed the orders were not properly authenticated with a date and time.

Based on medical record (MR) review and staff interview, it was determined the facility failed to ensure a medical history and physical was completed and documented by the physician within 24 hours after admission.

This deficient practice affected one of three inpatient MRs reviewed and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Patient Identifier (PI) # 8 was admitted to the facility on 5/24/25 with a diagnosis of medical detox.

MR review revealed a blank History and Physical form.

An interview was conducted on 6/26/25 at 2:43 PM with Employee Identifier # 1, Chief Nursing Officer, who confirmed there was no documentation of a history and physical being completed.

Based on medical record (MR) review and staff interview, it was determined the facility failed to ensure nurse's notes and withdrawal assessments were completed for each patient.

This deficient practice affected two of two substance abuse MRs reviewed and had the potential to affect all patients admitted to the facility.

Findings include:

1. Patient Identifier (PI) # 8 was admitted to the facility on 5/24/25 with a diagnosis of medical detox.

MR review revealed no documentation of nurse's notes on 5/21/25 or 5/23/25.

An interview was conducted 6/26/25 at 2:43 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed there were no nurse's notes documented on 5/21/25 or 5/23/25.

2. PI # 10 was admitted to the facility on 6/13/25 with a diagnosis of multisubstance drug abuse.

Review of the MR revealed no Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score completed on 6/16/25.

An interview was conducted on 6/26/25 at 2:39 PM with EI # 1, who confirmed there was no documentation of a CIWA score on 6/16/25. EI # 1 also confirmed the score should be assessed and documented daily by the nurse.

Based on medical record (MR) reviews, policies and procedures, Emergency Department (ED) diversion logs, and staff interviews, it was determined the facility failed to ensure laboratory (lab) services were available to all patients 24 hours a day.

This deficient practice had the potential to negatively affect all patients served by this facility and did affect Patient Identifier (PI) # 11, one of one inpatient death records reviewed.

Findings include:

Policy Name: Diversion Status

Department: Emergency Department

Policy Number: none

Revision Date: 07/2023

This policy outlines the procedure for declaring, maintaining, and terminating diversion status when the ED is overwhelmed or unable to safely accept additional patients.

Purpose: To establish a standardized protocol for initiating, managing, and terminating ED diversion status when patient volume and/or acuity exceeds the capacity of the ED to provide safe care.

Scope: This policy applies to all staff within the ED, hospital administration, nursing supervisors, Emergency Medical Services (EMS) liaisons, and other departments involved in ED operations...

1. A review of the ED Diversion Logs revealed the ED was on diversion on 6/12/25, 6/13/25, 6/16/25, 6/17/25, and 6/19/25 due to the hospital's inability to process critical labs.

2. A review of the lab calibration logs revealed the lab ran out of reagents and tips for the Vitros XT 3400 machine on 6/12/25. The lab was unable to process critical labs beginning on 6/13/25 to 6/24/25.

An interview was conducted on 6/25/25 at 1:10 PM with Employee Identifier (EI) # 2, Lab Director, who confirmed critical labs were unavailable for processing and reporting to meet the needs of the ED and inpatient services from 6/13/25 to 6/24/25.

An interview was conducted on 6/26/25 at 3:45 PM with EI # 5, Assistant Counselor/Tech for the Self Recovery Unit. EI # 5 stated from 6/13/25 to 6/24/25, the lab was unable to run an alcohol level which is required for admission to the self recovery unit. He/she confirmed that three patients were put "on hold" for admission approval due to the inability to process required admission labs.



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2. PI # 11 was admitted to the facility on 6/4/25 with a diagnosis of Pneumonia Unspecified Organism.

Review of the medical record for PI # 11 revealed a physician's order for a Metabolic Panel to be collected on 6/4/25, 6/5/25, 6/6/25 and 6/9/25.

Review of the lab results dated 6/4/25, 6/5/25, and 6/6/25 revealed no sodium, calcium or anion gap results which are included in a Metabolic Panel.

Further review of lab results dated 6/9/25 revealed no sodium, calcium, potassium, or anion gap results which are included in a Metabolic Panel.

An interview was conducted on 6/26/25 at 2:39 PM with Employee Identifier # 1, Chief Nursing Officer, who confirmed all lab services were not available to all patients 24 hours a day.

Based on the review of policies, laboratory (lab) calibration logs, diversion logs, radiology department issues form, and staff interview, it was determined the facility failed to ensure:

1. Emergency Department (ED) services were integrated with other departments within the hospital, including laboratory and radiology services.

2. Lab services were available to the ED for eleven days, starting on 6/13/25 and ending on 6/24/25.

3. Diversion Logs indicated an end time for the eight days the ED was on diversion in May 2025 and June 2025.

These deficient practices had the potential to negatively affect all patients presenting to the ED for treatment.

Findings include:

Policy Name: Diversion Status

Department: Emergency Department

Policy Number: none

Revision Date: 07/2023

This policy outlines the procedure for declaring, maintaining, and terminating diversion status when the ED is overwhelmed or unable to safely accept additional patients.

Purpose: To establish a standardized protocol for initiating, managing, and terminating ED diversion status when patient volume and/or acuity exceeds the capacity of the ED to provide safe care.

Scope: This policy applies to all staff within the ED, hospital administration, nursing supervisors, Emergency Medical Services (EMS) liaisons, and other departments involved in ED operations...

Review of the Hospital Diversion Logs for May 2025 and June 2025 revealed on 5/24/25 and 6/13/25 the hospital was on diversion due to not having radiological testing available.

On 5/24/25, diversion started at 4:00 AM due to "No radiology." No end time was documented.

On 6/13/25, diversion started at 7:00 PM due to "Radiology Down." No end time was documented.

Review of the Radiology Department Issues form revealed on 5/7/25 and 6/19/25, the computed tomography (CT) images would not electronically send. The radiologist is contracted and off site. This necessitates the need for electronic delivery of images for interpretation.

Further review of the Radiology Department Issues form revealed on 6/21/25, the employee scheduled to work called in sick. There was no available radiology staff to work the shift.

Review of the diversion logs revealed the facility was on diversion due to not having critical laboratory testing available on 5/24/25, 6/12/25, 6/13/25, 6/16/25, 6/17/25, and 6/19/25.

On 5/24/25, diversion started at 4:00 AM due to "No labs." No end time was documented.

On 6/12/25, 6/13/25, 6/17/25, and 6/19/25, diversion started at 7:00 PM due to "No labs." No end time was documented.

On 6/16/25, diversion started at 11:30 PM due to "No labs." No end time was documented.

On 6/25/25 at 1:10 PM, a review of the laboratory calibration logs and interview with Employee Identifier (EI) # 2, Laboratory Director, revealed critical labs were unavailable for processing and reporting to meet the needs of the ED patients from 6/13/25 to 6/24/25.

An interview conducted on June 26 at 3:00 PM with EI # 1, Chief Nursing Officer, confirmed the facility was not ensuring laboratory and radiology services were available 24/7 as required.

Based on the review of policies, the Staffing Plan for Hospital Nursing Services, nurse staffing schedules, diversion logs, patient census logs, and staff interview, it was determined the facility failed to ensure staffing of the Emergency Department (ED) was adequate to meet the needs of the patients and ensure patient safety.

This deficient practice had the potential to negatively affect all patients presenting to the ED for treatment.

Findings include:

Policy Name: Nursing Staffing

Department: All Hospital Units

Policy Number: none

Revision Date: 07/2023

Purpose: To ensure that appropriate nursing staff levels are maintained to deliver safe, high-quality care in a rural hospital setting, considering unique challenges such as limited workforce, financial constraints, and geographic isolation.

Policy Statement: This hospital commits to staffing nursing units with an appropriate number and mix of qualified nursing personnel based on patient acuity, census, available resources, and regulatory requirements...

Staffing Ratios:

...ED: Minimum of 1 Registered Nurse (RN) and 1 additional clinical staff 24/7...

Review of the Staffing Plan for Hospital Nursing Services provided to the surveyor by Employee Identifier (EI) # 1, Chief Nursing Officer (CNO) on 6/25/25 revealed the following statement: "The clinical staff works all three units each shift: (Med Surg; ED; and Detox)."


Policy Name: Diversion Status

Department: Emergency Department

Policy Number: none

Revision Date: 07/2023

This policy outlines the procedure for declaring, maintaining, and terminating diversion status when the ED is overwhelmed or unable to safely accept additional patients.

Purpose: To establish a standardized protocol for initiating, managing, and terminating ED diversion status when patient volume and/or acuity exceeds the capacity of the ED to provide safe care.

Scope: This policy applies to all staff within the ED, hospital administration, nursing supervisors, Emergency Medical Services (EMS) liaisons, and other departments involved in ED operations...

Review of the Hospital Diversion Logs for May 2025 and June 2025 revealed the hospital was on diversion due to a nursing shortage on 5/21/25, 5/28/25, 6/12/25, 6/16/25, 6/17/25, and 6/19/25.

On 5/21/25, 5/28/25, 6/12/25, 6/17/25, and 6/19/25, diversion started at 7:00 PM due to "Nursing shortage." No end time was documented.

On 6/16/25, diversion started at 11:30 PM due to "No nurse." No end time was documented.

Review of the staffing schedule for May 2025 and June 2025 revealed on 5/21/25, 5/28/25, and 6/16/25, there was one RN and one CNA scheduled for dayshift and nightshift. There was no RN scheduled for the ED 24/7 as directed in the facility policy.

On 6/17/25 there was one CNA working nightshift one RN working 11:00 PM to 7:00 AM. There was no RN scheduled for the ED 24/7 as directed in the facility policy.

Review of the patient census for 5/21/25 and 6/17/25, revealed five patients were seen in the ED on each day.

Review of the patient census for 5/28/25 revealed eleven patients were seen in the ED.

Review of the patient census for 6/16/25 revealed eight patients were seen in the ED.

There was only one RN on duty in the facility on the above dates requiring the nurse to leave inpatients without a nurse available while he/she cared for emergency room patients.

An interview conducted on June 26 at 3:00 PM with Employee Identifier # 1, Chief Nursing Officer, confirmed the facility was not following the policy for staffing the ED in order to ensure patient safety.