HospitalInspections.org

Based on the systemic nature of the standard-level deficiency related to governing body, the facility staff failed to substantially comply with this condition.

The findings were:

The following standard was cited and shows a systemic nature of non-compliance with regards to governing body as follows:

(482.12 Tag A-0057)
The information reviewed during the survey provided evidence that the facility failed to go on divert status in the Emergency Department (ED) on the 2300 to 0700 shifts on March 22 and 23, 2021 when the ED was not able to meet the laboratory demands of patients presenting to the ED.

A discussion took place with the survey team and facility administrative staff (EMP1, EMP2 and EMP11) regarding the survey team concerns related to Governing Body on March 30, 2021 at approximately 0940.

Based on the systemic nature of the standard-level deficiency related to laboratory services, the facility staff failed to substantially comply with this condition.

The findings were:

The following standard was cited and shows a systemic nature of non-compliance with regards to laboratory services as follows:

(482.27 Tag A-0583)
The information reviewed during the survey provided evidence that the facility failed to ensure the laboratory was staffed from 2300 to 0700 on March 22 and 23, 2021 and the facility failed to ensure a Medical Technologist was available to complete physician ordered routine and immediate laboratory testing of blood.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2 and EMP11) regarding the survey team's concerns related to Laboratory Services on March 30, 2021 at approximately 0940.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to go on divert status in the Emergency Department (ED) on the 2300 to 0700 shifts on March 22 and 23, 2021 when the ED was not able to meet the laboratory demands of patients presenting to the ED.

Findings include:

Review on March 30, 2021, of the facility's "Chief Executive Officer" job description, no review date, revealed "Summary: The Chief Executive Officer has full leadership and operational responsibility for the hospital. CEO will ensure success of the hospital through quality enhancement, cost containment, revenue growth and development of strong relationships with hospital staff ...Essential Duties and Responsibilities ... 3. Responsible for overall operations of the acute-care facility..."

Review on March 29, 2021, of the facility's "Scope of Care" policy, last revised October 9, 2020, revealed "Policy: Tyler Memorial Hospital Laboratory is a licensed, accredited full service hospital laboratory which offers a full range of Pathology and Clinical Laboratory testing. Procedure: The laboratory is operated, supervised and staffed by Pathologists, Medical Technologists, Phlebotomists and other professionals in laboratory science. In-house testing includes: Chemistry Special Chemistry Toxicology Hematology Coagulation Immunology Immunohematology Urinalysis. ..."

Review on March 29, 2021, of the facility's "Divert Status in the Emergency Department" policy, last revised April 23, 2020, revealed "Scope: This policy applies to situations when the demand for patient care in the Emergency Department (ED) exceeds the resources available to provide such care. ... Procedure: It is the responsibility of the ED physician, the ED director, House Supervisor and /or the administrator on call (AOC) to collaborate on the need to initiate divert status. ..."

Review on March 29, 2021, of the facility laboratory staffing schedule for March 22 and 23, 2021, revealed there were no laboratory staff scheduled to work on the 2300 to 0700 shifts on these days.

Interview with EMP1, EMP2 and EMP3 on March 29, 2021, at the time of the review, confirmed there were no laboratory staff scheduled to work on the 2300 to 0700 shifts on March 22 and 23, 2021.

Interview with EMP11 on March 20, 2021, at approximately 0955 confirmed this employee was aware there were no laboratory staff scheduled to work on the 2300 to 0700 shifts on March 22 and 23, 2021 and confirmed their position was the Chief Executive Officer.

Interview with EMP11 on March 30, 2021, at approximately 1035 confirmed the facility ED was not able to meet the needs of patients presenting to the ED needing laboratory testing on March 22 and 23, 202,1 between 2300 to 0700. EMP11 confirmed the facility did not consider putting the ED on divert status due to no available laboratory staff on these days from 2300 to 0700 and the ED was not placed on divert status.

Cross reference
482.12 Governing Body

Based on review of facility documents, review of medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure laboratory staff was available to complete physician ordered routine and immediate laboratory testing of blood for 24 hours a day, seven days a week.

Findings include:

Review on March 29, 2021, of the facility's "Scope of Care" policy, last revised October 9, 2020, "Policy: Tyler Memorial Hospital Laboratory is a licensed accredited full service hospital laboratory which offers a full range of Pathology and Clinical Laboratory testing. Procedure: The laboratory is operated, supervised and staffed by Pathologists, Medical Technologists, Phlebotomists and other professional in laboratory science. In-house testing includes: Chemistry Special Chemistry Toxicology Hematology Coagulation Immunology Immunohematology Urinalysis. All other testing is available through approved reference laboratories. Specimens are sent to them by way of courier and result are received by courier, fax and/or printer. ..."

Review on March 29, 2021, of the facility "Laboratory Manager" job description, last revised June 2018, revealed "Position Summary: The Laboratory Manager is responsible for planning, budgeting, developing, coordinating and evaluating all aspects within the Laboratory department. Maintains a close working relationships and open communication with staff, hospital administration and medical staff. ... Essential Duties and Responsibilities 1. Organizes and directs laboratory services to assure competent, cost effective, and quality delivery of patient care ..."

Review on March 29, 2021 of the facility "Laboratory Staffing Plan," last revised October 16, 2015, revealed "Policy Laboratory Staff Policy Procedure Minimum Staffing" The policy included a grid with the following documentation: Staff on Monday to Friday Day shift: 2 Med Techs (MT) and 2 Phlebotomist (Phleb) or 3 MTs and 1 Phleb; Evening Shift: 2 MTs and 1Phleb or 2 MTs and 0 Phleb; Night Shift: 1 MT; Saturday/Sunday/Holiday Day shift: 2 MTs and 1 Phleb; Evening Shift: 2 MTs and 0 Phleb and Night Shift: 1 MT. "Staffing: 1) A base schedule, with the same regular days off, is posted for six months or one year. Staff members on any shift may be asked to switch their shifts or regular days off to even out the staffing, and/or, to prevent a staff member from working more than 5 days in a row.... Continuity of Service During Adverse Weather Conditions or Call-Offs In the event of adverse weather conditions or other types of call-off from work, the following will apply 1. The laboratory adheres to HR Policy "Severe Weather". The department will be staffed 24 hours a day, 7 days a week. 2. When the call off, or weather emergency, occurs on day shift, Monday - Friday, the Lab Supervisor will make determinations of staffing requirements and obtain coverage, as needed. 3. When the call off, or weather emergency, occurs on weekends, evening or night shifts, the staff who are on duty will make determinations of staffing requirements and obtain coverage as needed. If there are any problems obtaining coverage, the Lab Supervisor is to be called. 4. An appropriate number of staff will remain on duty until relief staff has arrived. 5. Volunteers are always utilized first. If volunteers do not meet the staffing need, mandatory overtime will be assigned as necessary. 6. Coverage may be obtained as follows: a) The Lab Supervisor may fill in. b) Per-diem staff may be called. c) Staff from the previous shift may be asked to stay late, and staff from the following shift may be asked to come in early. d) Staff members who are off may be asked to come in and take another day off if possible. e) Staff members who are off may be asked to come in and be paid overtime if requirements are met. ... 8. The back-up schedule will be utilized. 9. The goals to be kept in mind when arranging staffing are: a) To provide adequate coverage for the shifst b) To add as little cost as possible to the payroll."

1. Review on March 29, 2021, of the facility laboratory staffing schedule for March 22 and 23, 2021, revealed there was no laboratory staff scheduled to work from 2300 to 0700 on these days.

Interview with EMP1, EMP2 and EMP3 on March 29, 2021, at the time of the review, confirmed there was no laboratory staff scheduled to work from 2300 to 0700 on March 22 and 23, 2021.

Review on March 30, 2021, of the facility laboratory staffing schedule for March 8, 13, 14, 16, 20, 21, 23 and 25, 2021, from 0700 to 1500 revealed EMP6 was the only Medical Technologist (MT) scheduled on these days.

Interview with EMP3 on March 30, 2021, at the time of the review, confirmed EMP6 was the only MT scheduled on these days. EMP6 was physically away from the laboratory for approximately 40 minutes to perform breast pumping. EMP6 is responsible for the completion of laboratory testing and notification of abnormal results. EMP3 confirmed laboratory testing and notification of abnormal results would need to wait for completion until EMP6 returned to the laboratory.

2. Review of MR1 on March 29, 2021, revealed this patient was admitted to the Emergency Department (ED) on March 22, 2021, at 2018 with complaint of chest and neck pain with a pain rating of 9 out of 10 with 10 being the worst kind of pain. The ED physician ordered a Troponin level (high blood levels indicate a person is having a possible heart attack or a possible stroke).

Review of MR1 on March 29, 2021, revealed this patient's first Troponin level was drawn by Tyler Memorial laboratory staff on March 22, 2021, at 2020. The test was run, resulted and reported to the ED physician on March 22, 2021 at 2057. The time from blood draw to results received was 37 minutes.

Review of on March 29, 2021, MR1 revealed the second Troponin level for this patient was drawn by the ED nursing staff at Tyler Memorial Hospital at 0010 on March 23, 2021 and was sent by courier to another facility approximately 45 minutes from Tyler Memorial Hospital. This second Troponin level was run and resulted at the other facility on March 23, 2021, at 0145 and the result was called to the ED physician at Tyler Memorial Hospital on March 23, 2021 at 0201. The time from blood draw to results received at Tyler Memorial Hospital was one hour and fifty minutes for the second Troponin level.

Interview with EMP1, EMP2 and EMP3 on March 29, 2021, at the time of review, confirmed MR1 was admitted to the ED on March 22, 2021, at 2018 with complaint of chest and neck pain with a pain rating of 9 out of 10 with 10 being the worst kind of pain. MR1's first Troponin level was drawn by Tyler Memorial laboratory staff on March 22, 2021, at 2020, was run, resulted and reported to the ED physician on March 22, 2021 at 2057. EMP1, EMP2 and EMP3 also confirmed MR1's second Troponin level was drawn by the ED nursing staff at Tyler Memorial Hospital at 0010 on March 23, 2021 and was sent by courier to another facility approximately 45 minutes from Tyler Memorial Hospital. The second Troponin level was run and resulted at the other facility on March 23, 2021, at 0145. The result was called to the ED physician at Tyler Memorial Hospital on March 23, 2021 at 0201. The time from blood draw to results received at Tyler Memorial Hospital was one hour and fifty minutes for the second Troponin level.

Interview with EMP3 on March 29, 2021, at approximately 1150 revealed the laboratory turnaround time for collecting, running and resulting a Troponin blood test is approximately 30 to 40 minutes and this is critical blood work when a physician is considering treatment for a heart attack or a stroke.

Cross reference
482.27 Laboratory Services