HospitalInspections.org

Based on facility document review, observation, and staff interview, it was determined the facility failed to ensure it met the hospital [provider] regulatory requirement for basis and scope, as defined by 42 CFR 482.1 and the Social Security Act, Section 1861(e). This failure resulted in the inability of the facility to be primarily engaged for inpatients and ensure the regulatory requirements of a hospital [provider], as defined by the Social Security Act, Medicare, and Medicaid, were met. Findings include:

The facility failed to meet the regulatory requirements of a hospital [provider]. Examples include:

1. The facility failed to ensure an ADC of at least 2 inpatients and an ALOS of at least 2 midnights.

a. Surveyors attempted to enter the facility on 4/02/18, beginning at approximately 1:00 PM. The doors to the facility were locked and the internal lights were off. The outside of the facility did not have posted hours of operation. A buzzer/button near the facility entrance was pressed and, shortly after, the doors were opened from the inside by the Charge Nurse. Once the surveyors were inside the facility, the Charge Nurse turned the overhead lights on.

The Charge Nurse was interviewed on 4/02/18, beginning at approximately 1:00 PM. She stated the facility had no current inpatients and she was the only staff person present. The Charge Nurse stated there were no scheduled surgeries or pending inpatient admissions for that day.

The facility did not have a minimum of 2 inpatients.

b. The facility Manager was interviewed on 4/02/18, beginning at 2:40 PM. When asked what the facility's average daily patient census was, he provided a document which stated:

- 2016 ADC 0.39 Patients
- 2017 ADC 0.35 Patients
- 2018 ADC 0.39 Patients

The facility Manager confirmed the facility's average daily census for 2016, 2017, and 2018 [thus far] was less than 2 inpatients.

The facility did not have an ADC of at least 2 inpatients.

c. The facility inpatient/outpatient register, from April 2017 to March 2018, was reviewed. The register for that time period identified 184 admissions, 74 (40%) inpatients and 110 (60%) outpatients.

i. Of the 74 registered as inpatients, 34 (46%) had an ALOS less than 2 midnights.

The facility failed to ensure its inpatient ALOS was at least 2 midnights.

ii. Of the 184 admissions, there were no admissions on a Saturday or Sunday for the 12 month period reviewed.

Admission patterns documented the facility routinely operated in a manner that its designated inpatient beds were not in use on weekends.

2. The facility Manager was interviewed on 4/02/18, beginning at 2:30 PM. When asked where patient clinical records were maintained, he stated they were available online via the facility's EMR system. When asked where patients' original, hard-copy clinical records were maintained, he stated they were stored at an affiliated critical access hospital located in the same city as the facility. The Manager confirmed patients' medical records were not maintained on-site.

The facility failed to ensure medical records were maintained.