HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to comply with all applicable Federal, State and Local laws regarding payment of Federal tax withholding, Social Security and Medicare, unemployment compensation, long term and short term disability, life insurance, employee 401k retirement savings accounts, child support, and union dues.

Findings include:

Review on March 23, 2012, of the facility's "Board of Trustee Bylaws of Saint Catherine Medical Center Fountain Springs," last reviewed and revised February 27, 2012, revealed "Article I General Scope Be it resolved by the Board of Trustees of Saint Catherine Medical Center Fountain Springs that the bylaws set out shall govern the transaction of the business and affairs of the Hospital. 1.1 Purpose The purpose, goals and objectives of the Board of Trustees of Saint Catherine Medical Center Fountain Springs shall be to: 1.1(a) Support, manage and furnish facilities, personnel and services; provide diagnosis, medical, surgical and hospital care ... 1.1(g) Guard against any activity in or on behalf of the Hospital having, or tending to have, an undesirable effect upon the Hospital or the services it renders ... 1.1(h) Provide for overall institutional planning, with the participation of the Medical Staff, nursing department, and such other individuals as the governing Body deems appropriate ... Article III Membership and Meetings of the Board of Trustees ... 3.9 Responsibilities The Board shall be delegated responsibilities for the functions enumerated below, and related functions, subject to corporate policies, these bylaws and directives from the Corporation. ... The responsibilities and obligations of the Board shall include: ... 3.9(e) In consultation with the MEC [Medical Executive Committee], the Corporation and the CEO, formulating programs for efficient delivery of care, compliance with applicable law (including Medicare regulations and other applicable regulations) and development, review and revision of policies and procedures ..."

Review on March 23, 2012, of the facility's "Chief Financial Officer" job description, no review date, revealed "Statement of Purpose: Plan, organize, and direct the fiscal services department, including the development, interpretation, coordination, and administration of the hospital's policies on finance, accounting, insurance, financial/accounting systems internal controls, and auditing. Duties, Responsibilities and Essential job Functions: ... 6. Budget and Inventory Control: Develops and recommends annual operating budget for department. Develops and recommends annual capital budget for department. ... 11. Job Specifics: manage hospital's financial resources. Through subordinates, supervise and coordinate the functions of reimbursement, budget, patient accounting, and general accounting, which includes [sic] general ledger accounting, accounts payable and cashiering. ... Establish and maintain appropriate records and reports. ..."

1) Review on March 23, 2012, of the facility's deposit confirmation regarding Federal tax withholding, Social Security and Medicare revealed the last deposit made by the facility was for the pay period ending March 2, 2012.

Interview with EMP5 on March 23, 2012, at approximately 9:30 AM confirmed the facility's last deposit confirmation for the Federal tax withholding, Social Security and Medicare was for the pay period ending March 2, 2012, and these deposits are required to be made with each pay period. Further interview with EMP5 revealed the facility's last pay date was March 16, 2012, and the payment for Federal tax withholding, Social Security and Medicare was not sent.

2) Review on March 23, 2012, of the facility's long term and short term disability and life insurance vendor provided by EMP5 revealed the last cleared payment made to this vendor was on September 29, 2011, for $19,035.94.

Interview with EMP5 on March 23, 2012, at approximately 9:30 AM confirmed the long term and short term disability and life insurance vendor's last payment was on September 29, 2011, for $19,035.94. Further interview with EMP5 revealed the facility sent a check to this vendor on February 2, 2012, to cover September, October, November and December 2011 and January 2012. EMP5 confirmed the check for $36,570.31 remains outstanding as of March 23, 2012.

Interview with EMP8 on March 23, 2012, at approximately 2:30 PM revealed the employer paid employee long term disability benefit policy was terminated by the vendor retroactive to August 31, 2011, due to non-payment. EMP8 revealed the employer paid benefit group life insurance was also terminated by the vendor retroactive to August 31, 2011. EMP8 revealed these benefits continued to be deducted from the employee pay checks.

3) Review on March 23, 2012, of the facility's Unemployment Compensation quarterly tax forms for the second quarter 2011, which included April, May and June 2011, revealed the facility submitted $30,237.44 on August 22, 2011, 22 days after the scheduled payment was due.

Interview with EMP5 on March 5, 2012, at approximately 9:35 AM confirmed the second quarter 2011 Unemployment Compensation was due July 31, 2011, and the facility sent the payment on August 22, 2011, 22 days after the scheduled payment was due.

4) Review on March 23, 2012, of the facility's Unemployment Compensation quarterly tax forms for the third quarter 2011, which included July, August and September 2011, revealed the facility submitted $10,281.44 on December 27, 2011, 57 days after the scheduled payment was due.

Interview with EMP5 on March 5, 2012, at approximately 9:40 AM confirmed the third quarter 2011 Unemployment Compensation was due October 31, 2011, and the facility sent the payment on December 27, 2011, 57 days after the scheduled payment was due.

5) Review on March 23, 2012, of the facility's Unemployment Compensation quarterly tax forms for the fourth quarter 2011, which included October, November and December 2011, revealed the facility submitted $6420.71 on February 20, 2012, 20 days after the scheduled payment was due.

Interview with EMP5 on March 5, 2012, at approximately 9:45 AM confirmed the fourth quarter 2011 Unemployment Compensation was due December 31, 2011, and the facility sent the payment on February 20, 2012, 20 days after the scheduled payment was due.

6) Review on March 23, 2012, of the facility's employee 401k investment inquiry printout provided by EMP5 for the date range January 1, 2011, to March 22, 2012, revealed the last payment made to the employees' 401k vendor was dated November 11, 2011, for $4,330.89.

Interview with EMP5 on March 23, 2012, at approximately 10:00 AM confirmed the last payment made to the employees' 401k vendor was on November 11, 2011, and no additional payments were made by the facility for 2011. EMP5 revealed the facility made no payments during 2012 to the employees' 401k retirement savings accounts.

7) Review on March 23, 2012, of EMP7's child support payment history provided by EMP5 revealed the last child support for EMP7 was paid March 9, 2012.

Interview with EMP5 on March 23, 2012, at approximately 10:05 AM confirmed EMP7 is required to pay child support; that child support is taken from every pay; and the last child support paid was on March 9, 2012. Further interview with EMP5 revealed the facility's last pay date was March 16, 2012.

8) Review on March 23, 2012, of facility documentation revealed the facility has three union vendors. Review of the first union vendor inquiry printout provided by EMP5 revealed the last payment to this vendor was on December 30, 2011.

Interview with EMP5 on March 23, 2012, at approximately 10:10 AM confirmed the last payment made to this professional union vendor was on December 30, 2011, and that payments were to be made to the union with each pay period. Further interview with EMP5 revealed the facility's last pay date was March 16, 2012.

9) Review on March 23, 2012, of the facility's second union vendor inquiry printout provided by EMP5 revealed the last payment to this vendor was on March 2, 2012.

Interview with EMP5 on March 23, 2012, at approximately 10:10 AM confirmed the last payment made to this professional union vendor was on March 2, 2012, and that payments were to be made to the union with each pay period. Further interview with EMP5 revealed the facility's last pay date was March 16, 2012.

10) Review on March 23, 2012, of the facility's third union vendor inquiry printout provided by EMP5 revealed the last payment to this vendor was on March 6, 2012.

Interview with EMP5 on March 23, 2012, at approximately 10:10 AM confirmed the last payment made to this professional union vendor was on March 6, 2012, and that payments were to be made to the union with each pay period. Further interview with EMP5 revealed the facility's last pay date was March 16, 2012.

Based on review of facility documents and staff interview (EMP), it was determined that the governing body failed to ensure adequate supplies were maintained, failed to ensure money was available to for payment of facility incurred debt, failed to prepare and accept an annual operating budget for 2012 (A073), and failed to ensure emergency room patients were transferred to other facilities in a timely manner (A144).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Findings include:

Review on March 23, 2012, of the facility's "Board of Trustee Bylaws of Saint Catherine Medical Center Fountain Springs," last reviewed and revised February 27, 2012, revealed "Article I General Scope Be it resolved by the Board of Trustees of Saint Catherine Medical Center Fountain Springs that the bylaws set out shall govern the transaction of the business and affairs of the Hospital. 1.1 Purpose The purpose, goals and objectives of the Board of Trustees of Saint Catherine Medical Center Fountain Springs shall be to: 1.1(a) Support, manage and furnish facilities, personnel and services; provide diagnosis, medical, surgical and hospital care ... 1.1(h) Provide for overall institutional planning, with the participation of the Medical Staff, nursing department, and such other individuals as the governing Body deems appropriate ... Article III Membership and Meetings of the Board of Trustees ... 3.9 Responsibilities The Board shall be delegated responsibilities for the functions enumerated below, and related functions, subject to corporate policies, these bylaws and directives from the Corporation. ... The responsibilities and obligations of the Board shall include: 3.9(i) Reviewing and consulting with the CEO [Chief Executive Office] concerning the; long-range plan for the Hospital ... 3.9(o) Protecting the economic viability of the Hospital ... 3.9(p) In cooperation with the CEO, approving an annual operating budget; developing a long-term capital expenditure plan for at least a three (3) year period, including the year of the operating budget, and implementation of that plan ... Article VI Chief Executive Office ... 6.1 Appointment of Chief Executive Officer ... The CEO shall have the authority to, and be held responsible for, administering the Hospital in all of its activities, subject only to such policies as may be adopted and such orders as may be issued by Corporation [sic]. ... 6.3 Chief Executive Officer's Responsibility the authority and duties of the CEO shall include responsibility for the following: 6.3(g) Supervising business affairs to ensure that funds are collected and expended to the best possible advantage ..."

Review on March 23, 2012, of the facility's "Chief Financial Officer" job description, no review date revealed "Statement of Purpose: Plan, organize, and direct the fiscal services department, including the development, interpretation, coordination, and administration of the hospital's policies on finance, accounting, insurance, financial/accounting systems internal controls, and auditing. Duties, Responsibilities and Essential Job Functions: ... 6. Budget and Inventory Control: Develops and recommends annual operating budget for department. Develops and recommends annual capital budget for department. Monitors budgetary compliance and addresses variances in all expense categories. Play active role in controlling inventory of supplies. Participates in cost-containment activities. ... 8. Planning ... Maintains compliance with regulatory requirements. ... 11. Job Specifics: manage hospital's financial resources. Through subordinates, supervise and coordinate the functions of reimbursement, budget, patient accounting, and general accounting, which includes [sic] general ledger accounting, accounts payable and cashiering. ... Participate in development of department operating budget and insure that operations are maintained within allocated funds. Establish and maintain appropriate records and reports. ... Recommend budget planning guidelines to board director, coordinate preparation of current operating and capital budgets with Administrator for hospital and clinics, present hospital-wide budgets to director for review and board approval. ..."

Review on March 23, 2012, of the facility's "Chief Executive Officer" job description, no review date revealed "Statement of Purpose: Responsible to provide leadership, direction, and administration if all aspects of hospital activities and other corporate entities to insure compliance with established objectives of quality, economical health care services and other related lines of business. ... 6. Budget and Inventory Control: Develops and recommends annual operating budget for department. Develops and recommends annual capital budget for department. Monitors budgetary compliance and addresses variances in all expense categories. ..."

1) Review on March 23, 2012, of the facility's Nursing Administration report dated February 18, 2012, revealed documentation of an 18 day old infant who presented to the facility's emergency department (ED). Further review of this report revealed there were no pediatric/infant electrodes (pads placed on the chest and attached to a machine to monitor the heart rate and rhythm) or pulse oximetry (a machine which monitors oxygen level of the blood) available in the ED.

Interview with EMP2 and EMP3 on March 23, 2012, at approximately 11:00 AM confirmed there were no pediatric/infant electrodes or pulse oximetry machine available in the ED to treat this infant presenting to the ED.

2) Review on March 23, 2012, of the facility's Nursing Administration report dated February 19, 2012, revealed documentation at 7:00 PM the facility was completely out of central venous pressure (CVP - a catheter inserted into the heart to measure blood flow pressure in the heart) kits.

Interview with EMP2 and EMP3 on March 23, 2012, at approximately 11:15 AM confirmed on February 19, 2012, at 7:00 PM the facility was completely out of CVP kits. Further interview with EMP2 revealed the ED physician indicated the ED was not safe, and two CVP kits were obtained from a nearby hospital.

3) Review on March 23, 2012, of the facility's Nursing Administration report dated February 24, 2012, revealed documentation at 7:00 AM the facility's intensive care unit (ICU) was completely out of syringes and needles.

Interview with EMP2 and EMP3 on March 23, 2012, at approximately 11:30 AM confirmed on February 24, 2012, at 7:00 AM the ICU was completely out of syringes and needles. Further interview with EMP2 revealed syringes and needles were obtained from other areas of the hospital.
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On March 23, 2012, EMP5 provided the survey team with a listing of vendors utilized by the facility. EMP5 identified the vendors on this list as: 1) Vendors the facility was not able to utilize until the account was paid in full. These vendors placed the facility's account on hold and orders would not be accepted from the facility. 2) Vendors that placed the facility on a payment plan. 3) Vendors that required the facility to provide cash on delivery (COD) for any orders placed by the facility.

On March 27, 2012, EMP5 provided the survey team with the outstanding balances identified on the vendor list. Interview with EMP5 on March 27, 2012, at approximately 12:30 PM confirmed there were 76 vendors on this list with outstanding balances due.

The following are the list of facility vendors; the amount of the outstanding balance on the account, and the account status:

1) Review on March 27, 2012, of the facility's chemistry analyzer vendor revealed an outstanding balance of $8491.06 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

2) Review on March 27, 2012, of the facility's nutritional supplement vendor revealed an outstanding balance of $1804.88 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility.

3) Review on March 27, 2012, of the facility's preventative maintenance vendor revealed an outstanding balance of $23,750.00 as of March 27, 2012. This vendor placed the facility on hold. Interview with EMP5 revealed the facility was not able to order from this vendor until the outstanding balance was paid in full.

4) Review on March 27, 2012, of the facility's first laboratory supply vendor revealed an outstanding balance of $18,118.08 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

5) Review on March 27, 2012, of the facility's blood supply vendor revealed an outstanding balance of $23,381.86 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility and placed the facility on a payment plan for the remaining balance due.

6) Review on March 27, 2012, of the facility's first operating room orthopedic supply vendor revealed an outstanding balance of $6809.45 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

7) Review on March 27, 2012, of the facility's behavioral telemedicine vendor revealed an outstanding balance of $51,570.00 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

8) Review on March 27, 2012, of the facility's second laboratory supply vendor revealed an outstanding balance of $289,432.78 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility and placed the facility on a payment plan for the remaining balance due.

9) Review on March 27, 2012, of the facility's third laboratory supply vendor revealed an outstanding balance of $2100.00 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

10) Review on March 27, 2012, of the facility's coal heating vendor revealed an outstanding balance of $24,390.00 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility and placed the facility on a payment plan for the remaining balance due.

11) Review on March 27, 2012, of the facility's pathology vendor revealed an outstanding balance of $1844.00 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

12) Review on March 27, 2012, of the facility's water vendor revealed an outstanding balance of $13,500.00 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

13) Review on March 27, 2012, of the facility's bread supply vendor revealed an outstanding balance of $2100.00 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

14) Review on March 27, 2012, of the facility's first medical equipment supply vendor revealed an outstanding balance of $4406.79 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

15) Review on March 27, 2012, of the facility's generator inspection and repair vendor revealed an outstanding balance of $18,961.21 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

16) Review on March 27, 2012, of the facility's first operating room equipment supply vendor revealed an outstanding balance of $708.11 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

17) Review on March 27, 2012, of the facility's biohazard waste disposal vendor revealed an outstanding balance of $1000.00 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility and placed the facility on a payment plan for the remaining balance due.

18) Review on March 27, 2012, of the facility's second operating room orthopedic equipment supply vendor revealed an outstanding balance of $19,993.12 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

19) Review on March 27, 2012, of the facility's waste disposal vendor revealed an outstanding balance of $11,483.98 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility and placed the facility on a payment plan for the remaining balance due.

20) Review on March 27, 2012, of the facility's emergency department physician vendor revealed an outstanding balance of $101,822.00 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

21) Review on March 27, 2012, of the facility's electronic billing vendor revealed an outstanding balance of $18,218.35 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

22) Review on March 27, 2012, of the facility's second medical equipment supply vendor revealed an outstanding balance of $15,987.41 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

23) Review on March 27, 2012, of the facility's specialty bed vendor revealed an outstanding balance of $7000.00 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

24) Review on March 27, 2012, of the facility's computer system vendor revealed an outstanding balance of $119,166.84 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

25) Review on March 27, 2012, of the facility's behavioral health vendor revealed an outstanding balance of $401,885.10 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

26) Review on March 27, 2012, of the facility's laboratory and blood reagent supply vendor revealed an outstanding balance of $14,328.36 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

27) Review on March 27, 2012, of the facility's magnetic resonance imaging (MRI) vendor revealed an outstanding balance of $21,450.23 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility and placed the facility on a payment plan for the remaining balance due.

28) Review on March 27, 2012, of the facility's preventative maintenance and equipment repair vendor revealed an outstanding balance of $37,747.64 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

39) Review on March 27, 2012, of the facility's ventilation vendor revealed an outstanding balance of $19,033.52 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off and placed the facility on a payment plan for the remaining balance due.

40) Review on March 27, 2012, of the facility's wound care supply vendor revealed an outstanding balance of $1764.00 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

41) Review on March 27, 2012, of the facility's second operating room supply vendor revealed an outstanding balance of $1036.87 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

42) Review on March 27, 2012, of the facility's collection service vendor revealed an outstanding balance of $5221.41 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

43) Review on March 27, 2012, of the facility's shredding vendor revealed an outstanding balance of $660.00 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

44) Review on March 27, 2012, of the facility's background check service vendor revealed an outstanding balance of $3798.20 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

45) Review on March 27, 2012, of the facility's printer and copier vendor revealed an outstanding balance of $74,000.00 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

46) Review on March 27, 2012, of the facility's mailing and shipping vendor revealed an outstanding balance of $10,074.28 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

47) Review on March 27, 2012, of the facility's third operating room supply vendor revealed an outstanding balance of $378.45 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

48) Review on March 27, 2012, of the facility's fourth operating room supply vendor revealed an outstanding balance of $178.23 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility.

49) Review on March 27, 2012, of the facility's carpet cleaning vendor revealed an outstanding balance of $5008.50 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

50) Review on March 27, 2012, of the facility's physical therapy equipment supply vendor revealed an outstanding balance of $297.49 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

51) Review on March 27, 2012, of the facility's medical gas system vendor revealed an outstanding balance of $5308.50 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

52) Review on March 27, 2012, of the facility's patient satisfaction survey vendor revealed an outstanding balance of $15,380.52 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

53) Review on March 27, 2012, of the facility's diagnostic scope service vendor revealed an outstanding balance of $5926.55 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

54) Review on March 27, 2012, of the facility's elevator inspection and repair service vendor revealed an outstanding balance of $23,265.87 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off and placed the facility on a payment plan for the remaining balance due.

55) Review on March 27, 2012, of the facility's patient education service vendor revealed an outstanding balance of $3936.00 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

56) Review on March 27, 2012, of the facility's answering service vendor revealed an outstanding balance of $4030.55 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

57) Review on March 27, 2012, of the facility's attorney service vendor revealed an outstanding balance of $19,332.05 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

58) Review on March 27, 2012, of the facility's care measure submission service vendor revealed an outstanding balance of $29,540.65 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

59) Review on March 27, 2012, of the facility's fourth laboratory support vendor revealed an outstanding balance of $76,879.95 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

60) Review on March 27, 2012, of the facility's fifth laboratory supply vendor revealed an outstanding balance of $3226.50 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility.

61) Review on March 27, 2012, of the facility's milk supply vendor revealed an outstanding balance of $3962.31 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility and on a payment plan for the remaining balance due.

62) Review on March 27, 2012, of the facility's third medical equipment supply vendor revealed an outstanding balance of $9554.31 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

63) Review on March 27, 2012, of the facility's painting vendor revealed an outstanding balance of $1399.62 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

64) Review on March 27, 2012, of the facility's fourth medical equipment supply vendor revealed an outstanding balance of $11,611.21 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

65) Review on March 27, 2012, of the facility's boiler and plant operation vendor revealed an outstanding balance of $3221.92 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

66) Review on March 27, 2012, of the facility's radiology and film processor vendor revealed an outstanding balance of $3114.69 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

67) Review on March 27, 2012, of the facility's office equipment supply vendor revealed an outstanding balance of $10,000 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

68) Review on March 27, 2012, of the facility's second office equipment supply vendor revealed an outstanding balance of $1383.84 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

69) Review on March 27, 2012, of the facility's third office equipment supply vendor revealed an outstanding balance of $6000.00 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

70) Review on March 27, 2012, of the facility's food supply vendor revealed an outstanding balance of $12,207.63 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility and on a payment plan for the remaining balance due.

71) Review on March 27, 2012, of the facility's second radiology vendor revealed an outstanding balance of $3600.00 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

72) Review on March 27, 2012, of the facility's third operating room orthopedic equipment supply vendor revealed an outstanding balance of $134,741.00 as of March 27, 2012. This vendor placed the facility on COD for any orders to the facility.

73) Review on March 27, 2012, of the facility's phone vendor revealed an outstanding balance of $32,058.87 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.
74) Review on March 27, 2012, of the facility's electric vendor revealed an outstanding balance of $435,832.35 as of March 27, 2012. EMP5 revealed the facility last made a payment on this electric bill on September 15, 2011.
75) Review on March 27, 2012, of the facility's sewer vendor revealed an outstanding balance of $69,137.00 as of March 27, 2012. This vendor placed the facility on a payment plan for the remaining balance due.

76) Review on March 27, 2012, of the facility's fifth medical supply vendor revealed an outstanding balance of $2725.38 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

Interview with EMP2 and EMP5 on March 27, 2012, at approximately 12:00 PM confirmed the above outstanding balances; the vendors that placed the facility on hold for delivery of supplies; the vendors that require cash on delivery for supplies delivered; and the vendors that placed the facility on a payment plan for the outstanding balance due.

Cross reference
482.11 Compliance with Federal, State and Local Laws
482.12(d) Institutional Plan and Budget
482.13(c)(2) Patient Rights: Care in Safe Setting
482.26 Radiologic Services
482.27(a) Adequacy of Laboratory Services
482.41 Physical Environment
482.41(a) Maintenance of Physical Plant
482.41(b)(7) Fire Control Plans
482.41(c)(2) Facilities, Supplies, Equipment Maintenance
482.51 Surgical Services

Based on observation, review of facility documents, and staff interview (EMP), it was determined the facility failed to ensure the components and accessories for the x-ray equipment functioned properly.

Findings include:

Observation of EMP9 on March 23, 2012, revealed this employee adjusting the x-ray machine before taking x-rays.

Review on March 23, 2012, of the facility's "X-ray Equipment Performance and Compliance Evaluation" report, dated February 6, 2012, revealed the facility's x-ray machine failed the field size indicator accuracy in the perpendicular field. Further review revealed this piece broke off.

Review on March 23, 2012, of the "X-ray Equipment Performance and Compliance Evaluation Visual Inspection and Compliance Evaluation" report revealed "... 14. All components and accessories do not function properly. ..."

Review on March 23, 2012, of the facility's " X-ray Equipment Performance and Compliance Evaluation" report, dated March 5, 2012, revealed room one's x-ray machine parallel field size indicator was not calibrated correctly and staff were required to adjust this field by hand.

Interview with EMP9 on March 23, 2012, at approximately 10:15 AM revealed there was uncertainty of the x-ray clarity and reliability, as the staff had to adjust the machine each time an x-ray was completed. EMP9 confirmed repairing the x-ray machines was scheduled for January 2012. EMP9 confirmed repairing these machines was not a priority because of the amount of money it would cost.

Interview with EMP1 and EMP2 on March 23, 2012, confirmed EMP9 made them aware of the broken x-ray machines.

Based on review of facility documents, observation, and staff interview (EMP), it was determined that the facility failed to maintain a safe environment for the patients seeking care at Saint Catherine Medical Center by failing to maintain the preventative maintenance for the hospital's equipment in the respiratory department, the post anesthesia care unit, and emergency department (A701), failing to ensure the services for monitoring the hospital's fire alarm system were maintained (A714), failing to maintain two of the three remaining facility elevators in a safe manner to transport patient, staff, visitors and supplies, and failing to ensure the preventative maintenance (PM) was completed on the hospital's generators (A724).

The cumulative effect of these failures resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Cross reference
482.41(a) Buildings
482.41(b)(7) Fire Control Plans
482.41(c)(2) - Facilities, Supplies, Equipment Maintenance

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure the humidity levels in operating rooms 1, 2 and 3 were within the acceptable parameter of 35 to 60 percent.

Findings include:

Review on March 23, 2012, of the facility's "Environment in the Operating Room" policy, last reviewed September 2011, revealed "Purpose: To provide a safe, comfortable surgical environment. Policy: 1. Temperature and humidity in Operating Rooms will be checked daily. The following parameters should be maintained. Temperature: 62 degrees to 72 degrees Fahrenheit. Humidity: 35 percent to 60 percent. ... Procedure: ... 5. Call Plant Operations, and send work order, to inform them if temperature and/or humidity is [sic] not within acceptable parameters. ... 6. If you are informed by maintenance that an adjustment cannot be made at that time ... contact the Department manager and first care surgeon(s) ... and inform them of possible cancellation or delay. ..."

1) Review on March 23, 2012, of the facility's documented humidity levels for operating room 1 for August 2011 revealed the humidity was above 60 percent on August 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 16, 17, 18, 19, 21, 22, 24, 25 and 26, 2011.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 2 for August 2011 revealed the humidity was above 60 percent on August 1, 2, 3, 4, 5, 7, 8, 9, 10, 15, 16, 18, 19, 22 and 24, 2011.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 3 for August 2011 revealed the humidity was above 60 percent on August 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 16, 17, 18, 19, 22, 24, 25 and 26, 2011.

2) Review on March 23, 2012, of the facility's documented humidity levels for operating room 1 for September 2011 revealed the humidity was above 60 percent on September 1, 2, 6, 7, 8, 9, 12, 13, 14, 15, 20, 22, 23, 26, 27, 28, 29 and 30, 2011.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 2 for September 2011 revealed the humidity was above 60 percent on September 1, 2, 6, 7, 8, 9, 12, 13, 14, 15, 20, 22, 26, 27, 29 and 30, 2011.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 3 for September 2011 revealed the humidity was above 60 percent on September 1, 2, 6, 7, 8, 9, 12, 13, 14, 15, 16, 20, 22, 23, 26, 27, 28 and 29, 2011.

3) Review on March 23, 2012, of the facility's documented humidity levels for operating room 1 for October 2011 revealed the humidity was above 60 percent on October 13, 19 and 20, 2011. Further review revealed the humidity was below 35 percent on October 18 and 28, 2011.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 2 for October 2011 revealed the humidity was above 60 percent on October 11, 13, 19 and 20, 2011. Further review revealed the humidity was below 35 percent on October 12, 18 and 28, 2011.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 3 for October 2011 revealed the humidity was above 60 percent on October 11, 13, 19 and 20, 2011. Further review revealed the humidity was below 35 percent on October 18 and 28, 2011.

4) Review on March 23, 2012, of the facility's documented humidity levels for operating room 1 for November 2011 revealed the humidity was below 35 percent on November 7, 17 and 18, 2011.

5) Review on March 23, 2012, of the facility's documented humidity levels for operating room 1 for December 2011 revealed the humidity was below 35 degrees on December 1, 13, 14 and 19, 2011.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 3 for December 2011 revealed the humidity was below 35 percent on December 1, 13, 14 and 19, 2011.

6) Review on March 23, 2012, of the facility's documented humidity levels for operating room 1 for January 2012 revealed the humidity was below 35 percent on January 3, 4, 5, 6, 10, 11, 18, 19, 20, 23, 25, 26, 30 and 31, 2012.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 2 for January 2012 revealed the humidity was below 35 percent on January 3, 4, 5, 10, 11, 18, 19, 20, 25, 28, 30 and 31, 2012.

Review on March 23, 20112, of the facility's documented humidity levels for operating room 3 for January 2012 revealed the humidity was below 35 percent on January 3, 4, 5, 6, 10, 11, 12, 18, 19, 20, 23, 25, 26, 30 and 31, 2012.

7) Review on March 23, 2012, of the facility's documented humidity levels for operating room 1 for February 2012 revealed the humidity was below 35 percent on February 3, 6, 7, 8, 9, 14, 15, 16, 21, 19, 23, 28 and 29, 2012.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 2 for February 2012 revealed the humidity was below 35 percent on February 2, 3, 6, 7, 8, 9, 14, 16, 21 and 22, 2012.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 3 for February 2012 revealed the humidity was below 35 percent on February 2, 3, 6, 7, 8, 9, 14, 15, 16, 21, 22, 23, 28 and 29, 2012.

8) Review on March 23, 2012, of the facility's documented humidity levels for operating room 1 for March 2012 revealed the humidity was below 35 percent on March 6, 7 and 13, 2012.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 2 for March 2012 revealed the humidity was below 35 percent on March 7, 8, 13 and 15, 2012.

Review on March 23, 2012, of the facility's documented humidity levels for operating room 3 for March 2012 revealed the humidity was below 35 percent on March 2, 6, 7, 13, 14, 15 and 23, 2012.

Interview with EMP3, EMP6 and EMP7 on March 23, 2012, at approximately 3:00 PM confirmed that the humidity's in all three operating rooms had not been within the acceptable range since August 2011. EMP3 revealed the maintenance department continued to make adjustments. EMP3 confirmed the air handlers were in need of repair. The facility's contracted vendor will not perform the work until the outstanding balance of $19,033.52 is paid in full. Interview with EMP5 revealed the vendor placed a hold on any work requested by the facility until the outstanding balance is paid in full.

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Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure medical/surgical devices and equipment were checked and maintained routinely by clinical/biomedical engineers in the facility's operating rooms.

Findings include:

Review on March 23, 2012, of the facility's "Medical Equipment Management Plan" policy, last reviewed December 2012, revealed "I Purpose The purpose of the medical Equipment Management Plan is to support a safe patient care and treatment environment at Saint Catherine Medical Center (SCMCFS) by managing risks associated with the use of clinical equipment technology. The program includes processes for selection and maintenance of equipment designed to assure safe and appropriate support of patient care services. The selection and management processes are based on the risks associated with the equipment. ... IV Objectives A. to provide a safe environment through proper selection, use, testing and maintenance of Medical Equipment ... D. To identify deficiencies, failures and user errors to help prevent unnecessary injury to patients. V. ... B. The CEO receives regular reports of the current status of the Medical Equipment program ... C. The Biomedical Engineering Contractor assures that the biomedical equipment plan is implemented in all key clinical areas. ... The Biomedical Engineering Contractor implements the in-house medical equipment maintenance program and tracks maintenance provided by original equipment manufactures, [sic] and other contractors who provide maintenance and repair services for specific items of equipment. ..."

1) Observation on March 23, 2012, of the facility's operating room camera revealed the preventative maintenance was schedule for February 2012.

Interview with EMP2, EMP3 and EMP6 on March 23, 2012, at approximately 1:00 PM confirmed the preventative maintenance on the operating room camera was not performed in February 2012.

2) Observation on March 23, 2012, of the facility's anesthesia machine with monitor revealed the last preventative maintenance was performed in August 2011. Further observation revealed this machine was scheduled for preventative maintenance in February 2012.

Interview with EMP2, EMP3 and EMP6 on March 23, 2012, at approximately 1:05 PM confirmed the preventative maintenance on the anesthesia machine with monitor was last performed in August 2011, and the scheduled February 2012 preventative maintenance was not performed.

3) Observation on March 23, 2012, of the facility's operating room revealed two anesthesia ventilation machines. The first anesthesia machine's last preventative maintenance was performed February 2011. Further observation revealed this machine was scheduled for preventative maintenance in August 2011.

Interview with EMP2, EMP3 and EMP6 on March 23, 2012, at approximately 1:10 PM confirmed the preventative maintenance on this anesthesia machine was performed February 2011, and the scheduled August 2011 preventative maintenance was not performed. EMP6 confirmed that the facility used this machine on patients without completing the preventative maintenance.

4) Observation on March 23, 2012, of the facility's operating room revealed the second anesthesia machine's last preventative maintenance was performed April 2011. Further observation revealed this machine was scheduled for preventative maintenance in October 2011.

Interview with EMP2, EMP3 and EMP6 on March 23, 2012, at approximately 1:15 PM confirmed the preventative maintenance on this anesthesia machine was performed April 2011, and the scheduled October 2011 preventative maintenance was not performed. EMP6 confirmed that the facility used this machine on patients without completing the preventative maintenance.

Interview with EMP2 and EMP5 on March 23, 2012, at approximately 2:00 PM confirmed the anesthesia machines' preventative maintenance was to be completed quarterly. EMP5 revealed the vendor responsible for completing the preventative maintenance will not perform the work until the outstanding balance of $23,750.00 is paid in full.

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to have a prepared and accepted annual operating budget for 2012.

Findings include:

Review on March 23, 2012, of the facility's "Board of Trustee Bylaws of Saint Catherine Medical Center Fountain Springs," last reviewed and revised February 27, 2012, revealed "Article I General Scope Be it resolved by the Board of Trustees of Saint Catherine Medical Center Fountain Springs that the bylaws set out shall govern the transaction of the business and affairs of the Hospital. 1.1 Purpose The purpose, goals and objectives of the Board of Trustees of Saint Catherine Medical Center Fountain Springs shall be to: ... 1.1(h) Provide for overall institutional planning ... Article III Membership and Meetings of the Board of Trustees ... 3.9 Responsibilities The Board shall be delegated responsibilities for the functions enumerated below, and related functions, subject to corporate policies, these bylaws and directives from the Corporation. ... The responsibilities and obligations of the Board shall include: 3.9(i) Reviewing and consulting with the CEO [Chief Executive Office] concerning the; long-range plan for the Hospital ... 3.9(o) Protecting the economic viability of the Hospital ... 3.9(p) In cooperation with the CEO, approving an annual operating budget; developing a long-term capital expenditure plan for at least a three (3) year period, including the year of the operating budget, and implementation of that plan ... "

Review on March 23, 2012, of the facility's "Chief Financial Officer" job description, no review date revealed "Statement of Purpose: Plan, organize, and direct the fiscal services department, including the development, interpretation, coordination, and administration of the hospital's policies on finance, accounting, insurance, financial/accounting systems internal controls, and auditing. Duties, Responsibilities and Essential job Functions: ... 6. Budget and Inventory Control: Develops and recommends annual operating budget for department. Develops and recommends annual capital budget for department. ... 11. Job Specifics: manage hospital's financial resources. Through subordinates, supervise and coordinate the functions of reimbursement, budget, patient accounting, and general accounting, which includes [sic] general ledger accounting, accounts payable and cashiering. ... Participate in development of department operating budget and insure that operations are maintained within allocated funds. Establish and maintain appropriate records and reports. ... Recommend budget planning guidelines to board director, coordinate preparation of current operating and capital budgets with Administrator for hospital and clinics, present hospital-wide budgets to director for review and board approval. ..."

Review on March 23, 2012, of the facility's "Chief Executive Officer" job description, no review date revealed "Statement of Purpose: Responsible to provide leadership, direction, and administration if all aspects of hospital activities and other corporate entities to insure compliance with established objectives of quality, economical health care services and other related lines of business. ... 6. Budget and Inventory Control: Develops and recommends annual operating budget for department. Develops and recommends annual capital budget for department. Monitors budgetary compliance and addresses variances in all expense categories. ..."

Review on March 23, 2012, of the facility's Board of Trustees Meeting minutes from the September 26, 2011, October 24, 2011, and November 28, 2011, revealed no documentation the Chief Financial Officer or the Chief Executive Officer developed, presented or recommended an annual operating budget for 2012.

Interview with EMP2, EMP5 and EMP8 on March 27, 2012, at approximately 12:00 PM confirmed the facility does not have a 2012 year budget and a 2012 budget was not developed or approved by the governing body.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to provide patients with timely transfers from the emergency department to other hospitals for three of three transfer records reviewed (MR13, MR14 and MR15).

Findings include:

Review on March 27, 2012, of the facility's "Patient Rights" document, no review date, revealed "As a patient of Saint Catherine Medical Center Fountain Springs, you and your family are entitled to certain considerations based on either law, custom or moral obligation. The following list of entitlements has been established by the Board of Trustees, management and staff of Saint Catherine Medical Center Fountain Springs. Your rights include, but may not be limited to: ... Receive care in a safe setting that provides for you emotional health as well as physical safety. Expect that emergency procedures will be performed without unnecessary delay. ..."

1) Review of MR13 on March 27, 2012, revealed this patient presented to the facility's emergency department (ED) on March 26, 2012, with the complaint of abdominal pain. Further review of MR13 revealed the ED physician determined this patient was dehydrated, had a low potassium level, and had blood in the stool. The ED physician determined MR13's medical condition required admission to a hospital. The ED physician ordered transfer to another hospital for further treatment. MR13's transfer required advanced cardiac life support (ACLS) professionals. The receiving facility and physician were notified. It was determined MR13 was ready for transfer at 3:55 PM. MR13 left the facility at 5:45 PM, approximately two hours after the ED physician determined this patient required transfer.

Interview with EMP2 on March 27, 2012, at approximately 10:30 AM confirmed MR13 required admission to a hospital and transfer to another hospital due to the ban placed on admissions at Saint Catherine Medical Center. EMP2 confirmed this patient required ACLS professionals for transport. EMP2 confirmed MR13's time between the ED physician's determination MR13 was ready for transfer and when MR13 left the ED was approximately two hours.

2) Review of MR14 on March 27, 2012, revealed this patient presented to the facility's ED on March 26, 2012, with the complaint of shortness of breath and wheezing. The ED physician determined MR14's medical condition required admission to a hospital. The ED physician ordered a transfer of MR14 to another hospital for further treatment. MR14's transfer required basic life support (BLS) professionals. The receiving facility and physician were notified. It was determined MR14 was ready for transfer at 1:47 PM. MR14 left the facility at 3:45 PM, approximately two hours after the ED physician determined this patient required transfer.

Interview with EMP2 on March 27, 2012, at approximately 10:30 AM revealed MR14 required admission to a hospital and transfer to another hospital due to the ban placed on admissions at Saint Catherine Medical Center. EMP2 confirmed this patient required ACLS professionals for transport. EMP2 confirmed MR14's time between the ED physician's determination MR14 was ready for transfer and when MR14 left the ED was approximately two hours.

3) Review of MR15 on March 27, 2012, revealed this patient presented to the facility's ED on March 26, 2012, with complaint dizziness and weakness. Further review of MR15 revealed the ED physician determined this patient had an elevated Dilantin level and required specialized neurology treatment. The ED physician determined MR15 required transfer to another hospital for further treatment. MR15 required transfer with ACLS professionals. The receiving facility and physician were notified. It was determined MR15 was ready for transfer at 1:30 PM. MR15 left the facility at 2:40 PM, one hour and 10 minutes after the ED physician determined this patient required transfer.

Interview with EMP2 on March 27, 2012, at approximately 10:30 AM revealed MR15 required transfer to another hospital due to the requirement for specialized neurology treatment. EMP2 confirmed this patient required ACLS professionals for transport. EMP2 confirmed MR15's time between the ED physician's determination MR15 was ready for transfer and when MR15 left the ED was over one hour.

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure laboratory testing supplies were not used past the expiration date.

Findings include:

Observation of the facility's laboratory on March 22, 2012, revealed an expiration date of February 20, 2012, on the blood bank reagents. The blood bank reagents included antibody screening cells, reverse group cells, Coombs control check cells, and quality control kit. The chemistry immunoassay control expired on February 20, 2012. The expiration date on the microbiology negative panels for bacterial identification and sensitivity was March 2, 2012.

Interview with EMP11 on March 22, 2012, at approximately 1:30 PM confirmed the expired dates on the blood bank reagents, the blood chemistry controls, and the microbiology identification and sensitivity controls. Further interview with EMP11 revealed the laboratory department had not received a supply order since January 2012. EMP11 confirmed an order was placed in the beginning of February 2012. EMP11 confirmed no laboratory supplies were received. EMP11 confirmed the laboratory department continued to use the laboratory testing supplies that expired February 20, 2012 and March 2, 2012.

Based on review of facility documentation and staff interview (EMP), it was determined the facility failed to maintain the preventative maintenance for the hospital's equipment in the respiratory department, the post anesthesia care unit, and emergency department.

Findings include:

Review on March 23, 2012, of the facility's "Medical Equipment Management Plan" policy, last reviewed December 2011, revealed "I Purpose The purpose of the Medical Equipment Management Plan is to support a safe patient care and treatment environment at Saint Catherine Medical Center (SCMCFS) by managing risks associated with the use of clinical equipment technology. ... IV Objectives A. To provide a safe environment through proper selection, use, testing and maintenance of Medical Equipment ... To ensure Medical Equipment and staff perform at an acceptably [sic] level to limit the potential for patient injury due to equipment failure or misuse. ..."

Review on March 27, 2012, of the facility's preventative maintenance and equipment repair vendor revealed an outstanding balance of $37,747.64 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off.

Review on March 23, 2012, of the facility's equipment list and date of the last preventative maintenance was performed was provided to the survey team by EMP3.

1) Review on March 23, 2012, of the respiratory department preventative maintenance (PM) record revealed the (EKG) machine and the ventilators (breathing machines) were last checked in April 2011.

Interview with EMP3 on March 23, 2012, at approximately 1:00 PM revealed the PM was required to be completed every six months on these machines. EMP3 confirmed the PM was due in October 2011. Further interview with EMP3 revealed the facility continued to use these machines on patients. There was no documentation the PM was performed after April 2011.

2) Review on March 23, 2012, of the post anesthesia care unit (PACU) department PM record revealed the defibrillator (machine used to deliver shock to a stopped heart) machine was last checked August 2011.

Interview with EMP3 on March 23, 2012, at approximately 1:05 PM revealed the PM was required to be completed every six months on this machine. EMP3 confirmed the PM was due in February 2012. There was no documentation the PM was performed after August 2011.

3) Review on March 23, 2012, of the emergency department PM record revealed the defibrillator machines, one in the chest pain room, one in the the trauma room, and on in bed 3, were last completed March 2011.

Interview with EMP3 on March 23, 2012, at approximately 1:10 PM revealed the PM was required to be completed every six months on these machines. EMP3 confirmed the PM was due in September 2011. Further interview with EMP3 confirmed the facility used these machines on patients. There was no documentation the PM was performed after September 2011.

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure the services for monitoring the hospital's fire alarm system were maintained.

Findings include:

Review on March 23, 2012, of the facility's "Chief Executive Officer" job description, no review date, revealed "Statement of Purpose: Responsible to provide leadership, direction, and administration if all aspects of hospital activities and other corporate entities to insure compliance with established objectives of quality, economical health care services and other related lines of business. ..."

On March 23, 2012, EMP5 provided a letter sent to the facility with a certified return receipt slip from the facility's fire alarm system vendor. This letter was dated October 26, 2011. Review of this letter revealed the following "Please be advised that the monitoring of the fire alarm system at 101 Broad Street had been terminated as of Wednesday, 10/26/11. We have made numerous attempts to contact you to make arrangements for payment, and have continued the monitoring in good faith anticipation of payment of the yearly invoice for monitoring (... for $395.00), however we can no longer continue to do so. Please remit payment for the 4 months that have already been provided ($131.00). ..."

Review on March 23, 2012, of the fire alarm system inspection, testing and maintenance vendor invoice revealed this vendor tested the facility's fire system on January 12, 2012, and reported to EMP2 that the fire alarm system was not being monitored at the central monitoring station. Further review revealed the central fire monitoring station informed the fire alarm maintenance vendor that the account was cancelled on October 26, 2011. Further review revealed the facility did not have central station monitoring reinstated until February 16, 2012, four months after receiving notice of cancellation.

The facility was unable to provide documentation that staff had been advised that in the event of a fire, they were required to call the fire department to report a fire in the hospital.

Interview with EMP2 and EMP5 on March 23, 2012, at approximately 2:15 PM confirmed the facility received the certified letter regarding the cancellation of the facility's fire alarm central station monitoring system and the facility did not have central station fire alarm system monitoring for approximately four months. EMP2 confirmed that if the facility had a fire during those four months when there was no central station fire alarm system monitoring, staff would not have known to call the fire company. EMP2 revealed the purpose of the central station fire alarm system was for the fire alarm to go to the station without staff having to place a call.

Based on observation, review of facility documents and staff interview (EMP), it was determined that the facility failed to maintain two of the three facility elevators in a safe manner to transport patients, staff, visitors and supplies, failed to ensure the preventative maintenance (PM) was completed on the hospital's generators, and failed to ensure that the facility's supplies and equipment were maintained to ensure an acceptable level of safety and quality throughout the hospital.

Findings include:

1) Review on March 23, 2012, of the inspection report from the elevator inspection and repair vendor dated April 25, 2011, revealed the dietary elevator should be checked for proper positioning, the elevator is not centered and appears to have moved from the centered position.

Observation on March 27, 2012, of the dietary service elevator revealed the following: The surveyor entered the elevator on the 1st floor with EMP12. EMP12 selected the basement level on the elevator key pad. The elevator did not move. EMP12 then struck the elevator door with their hand. The elevator door closed further, and the elevator then began to move.

Interview with EMP4 on March 27, 2012, at approximately 10:00 AM confirmed the dietary service elevator was not working properly and pushing hard on the door was necessary to make the elevator work.

2) Review on March 23, 2012, of the inspection report from the elevator inspection and repair vendor dated April 25, 2011, revealed the second of the two facility main elevators had a worn front left and right roller; the counter weight rack roller guide assembly on the right and needs replaced; and the worn front and rear rollers for the bottom right and left counter weight rack roller guide assembly needs replaced.

Observation on March 22, 2012, revealed the elevator directly outside the dietary department contained signage that the elevator was out of service.

3) Observation on March 27, 2012, revealed there were two elevators located across the hallway from the elevator with signage that it was out of service. These two elevators were used to transport patients, visitors and staff. Observation on March 27, 2012, revealed the following. The surveyor entered Elevator 2 on the 1st floor with EMP2. EMP2 selected the 5th floor nursing station on the elevator key pad. The elevator began to move to the 5th floor. Elevator 2 vibrated and shook violently en route to the 5th floor. On return from the 5th floor to the 1st floor, Elevator 2 again responded. As the elevator returned to the 1st floor, it vibrated and shook violently. This entire episode was repeated a third time when this elevator was accessed on the 1st floor to return to the 5th floor with EMP10.

Interview with EMP2 March 27, 2012, at 9:15 AM confirmed the second (Elevator 2) of the two main elevators used to transport patients, visitors and staff vibrated and shook violently as it went up and down to each floor.

Interview with EMP10 March 27, 2012, at approximately 10:00 AM confirmed the second (Elevator 2) of the two main elevators used to transport patients, visitors and staff vibrated and shook violently as it went up and down to each floor.

4) Review on March 27, 2012, of the facility's elevator inspection and repair service vendor revealed an outstanding balance of $23,265.87 as of March 27, 2012. This vendor placed the facility on hold until the outstanding balance is paid off and placed the facility on a payment plan for the remaining balance due.

Interview with EMP5 on March 27, 2012, at approximately 12:00 PM confirmed the elevator inspection and repair service vendor's outstanding balance was $23,265.87 as of March 27, 2012. Further interview with EMP5 revealed this vendor placed the facility on hold until the outstanding balance is paid off and placed the facility on a payment plan for the remaining balance due. EMP5 confirmed the vendor will not perform any work until the entire bill is paid.

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Interview with EMP2, EMP3 and EMP5 on March 23, 2012, at approximately 2:00 PM revealed the facility has three generators. EMP2 identified these generators as critical care, life safety, and mechanical.

Review on March 23, 2012, of the facility's generator inspection and repair vendor service report dated May 20, 2011, revealed this vendor performed preventative maintenance on these generators requiring the removal of debris, completion of an inspection sheet, took oil and coolant samples, added new coolant and recommended cleaning of the radiator, as well as replacing the batteries every three years.

Review on March 23, 2012, of these generators revealed the next preventative maintenance was scheduled January 2012. There was no documentation preventative maintenance was completed on these generators in January, February or March 2012.

Interview with EMP2 on March 23, 2012, at approximately 11:15 AM confirmed these generators next preventative maintenance was scheduled January 2012. EMP2 confirmed there was no documentation preventative maintenance was completed on these generators in January, February or March 2012.

Review on March 27, 2012, of the facility's generator inspection and repair vendor revealed an outstanding balance of $18,961.21 as of March 27, 2012, and this vendor placed the facility on hold until the outstanding balance is paid off.

Interview with EMP5 on March 27, 2012, at approximately 11:45 AM confirmed the facility's generator inspection and repair vendor's outstanding balance of $18,961.21. EMP5 confirmed this vendor placed the facility on hold until the outstanding balance is paid off.

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Interview with EMP2 on March 23, 2012, revealed the census for the acute care hospital was 13 inpatients. EMP2 confirmed the facility outpatient clinics were providing care to outpatients. The facility also had a long term facility on the premises. The supplies for the long term care facility were stored in the medical supply store room of the hospital. Interview with EMP2 revealed the census in long term care was 28 residents.

Observation of the facility's medical supply inventory store room on March 23, 2012, at approximately 1:30PM revealed multiple empty shelves.

Interview with EMP10 on March 23, 2012, at approximately 1:30 PM revealed the facility's last medical supply order was received on March 16, 2012.

An inventory of the facility's medical supply inventory was completed with EMP10 and the state surveyor on March 23, 2012. The following items were identified:

1) There were zero 18 French foley catheter trays. The facility's determined stock quantity was 10.

2) There were zero boxes of size 7.5 surgical gloves. The facility's determined stock quantity was 50.

3) There was zero paper tape. The facility's determined stock quantity was 120.

4) There was zero durapore tape. The facility's determined stock quantity was 120.

5) There were zero 50 pack wash cloths. The facility's determined stock quantity was 20.

6) There were zero adult medium size diapers. The facility's determined stock quantity was 18.

7) There was zero lotion. The facility's determined stock quantity was 40.

8) There were zero adult large diapers. The facility's determined stock quantity was 108.

9) There were zero adult x-large diapers. The facility's determined stock quantity was 40. There were zero disposable bed pans. The facility's determined stock quantity was 24.

10) There was zero medicated soap. The facility's determined stock quantity was 24.

11) There was 1 safety glide 22 gauge syringe. The facility's determined stock quantity was 101.

12) There were 2 duoderm specialty dressings available. The facility's determined stock quantity was 12.

13) There were two 500 millimeter (ml) of sterile irrigation water. The facility's determined stock quantity was 24.

14) There were 20 non-adherent dressings. The facility's determined stock quantity was 120.

15) There were 120 sterile urine collection containers. The facility's determined stock quantity was 526.

16) There were 26 boxes of powder free examination gloves. The facility's determined stock quantity was 96 boxes.

17) There were 7 - 1200 cubic centimeters (cc) suction canisters. The facility's determined stock quantity was 67.

18) There were 59 safe glide 18 gauge syringes. The facility's determined stock quantity was 159.

19) There was one 20 gauge intravenous (IV) catheter. The facility's determined stock quantity was 201.

20) There was one chloraprep IV start kit. The facility's determined stock quantity was 201.

21) There were 6 bottles of mouth wash. The facility's determined stock quantity was 66.

22) There were 82 latex free hypoallergenic syringes. The facility's determined stock quantity was 207.

23) There were 8 urinals with covers. The facility's determined stock quantity was 56.

24) There were 8 secondary IV non vented sets. The facility's determined stock quantity was 104.

25) There was 1 secondary IV non vented 110 inch set. The facility's determined stock quantity was 193.

26) There were 22 bags of one-half normal saline 1000 millimeters (ml) IV solution. The facility's determined stock quantity was 64.

27) There were 20 bags of one-quarter normal saline 1000 ml IV solution. The facility's determined stock quantity was 104.

Interview with EMP10 on March 23, 2012, at approximately 1:45 PM confirmed the above findings. Further interview with EMP10 revealed that based on the quantity of supplies on the medical supply shelves, products were adequate for two or three days. EMP10 confirmed no order for patient medical supplies was placed due to the facility's poor line of credit.

Interview with EMP10 on March 27, 2012, at approximately 10:00 AM revealed supplies continued to be low. EMP10 confirmed with the ban on admissions the supplies were lasting longer. EMP10 confirmed no order was placed for hospital supplies. Further interview with EMP10 revealed vendors supplying inventory for the interventional radiology, ear nose and throat and sleep lab were scheduling pickups of their remaining equipment in the facility.