HospitalInspections.org

Based on medical record review, observation of facility bed location, facility floor map, administrative and staff interviews, the facility failed to meet the definition of a rural emergency hospital (REH) by admitting 1 patient (P5) categorized as a hospice inpatient which occupied 1/15 licensed observation hospital beds since 7/31/2024. This failed practice has the potential to cause regulatory negative outcomes related to care and services provided by the REH without a skilled nursing facility distinct part unit license. According to facility provided data the REH had 14 observation patients 1/11/2024 - 9/23/2024.

Findings include:

A. Review of P5's medical record revealed, P5 presented to the REH on 7/31/2024 at 10:30AM as a direct admit (patient goes directly from a facility to another facility without going through the emergency department or clinic) from a long-term care facility for 24/7 hospice care. P5's diagnosis revealed chronic myeloproliferative disease (bone marrow blood cancer).

P5's electronic medical record (EMR) revealed patient class as, "1-inpatient." During an interview with COO on 9/24/2024 at 11:43AM, the COO confirmed the medical record for P5 class type reads, "1-inpatient," and stated it should say observation but unable to change in the EMR.

B. A tour of the observation hospital unit on 9/24/2024 at 2:18PM revealed the REH licensed observation hospital beds are rooms 1-15. P5 is located in Room 6 (1/15) licensed observation hospital bed and has been receiving 24/7 direct patient care from the REH since 7/31/2024. The REH facility contracted with a hospice service for a Registered Nurse (RN) to be onsite for designated days of the week to assess and coordinate care, and a Certified Nursing Assistant (CNA) to provide whirlpool baths, all other care and treatment is provided by the REH staff.
Confirmed with RN-A on 9/24/2024 at 2:20PM.

C. Review of the facility floor map revealed room 6 is an observation room. Confirmed by RN-A on 9/23/2024 at 2:50PM.

D. During an interview on 9/24/2024 at 8:45AM, with CEO/CFO and COO revealed, the facility has been in contact with a third party to assist with the transition from a CAH to an REH since 1/11/2024. The CEO/CFO had a community meeting with the medical staff and governing body to discuss taking hospice patients. The board agreed that the facility is able to care for one hospice patient per year to keep the annual average length of stay under the 24-hour REH definition requirement.

Based on the rural emergency hospital (REH) action plan and attestation review, policy and procedure review, medical staff bylaws review, rules and regulations review, and administrative staff interviews the facility failed to have finalized medical staff bylaws, rules and regulations, and policies and procedures to address the post-acute care needs of observation patients receiving services at the REH. This failed practice has the potential to cause negative outcomes for all patients admitted for observation services provided by the REH. According to facility provided data the REH had 14 observation patients 1/11/2024 - 9/23/2024.

Findings include:

A. Review of the facility action plan and attestation to convert from a Critical Access Hospital (CAH) to an REH approved on 1/11/2024 revealed provision of services included observation services. The summary of conversion plan revealed discontinuation of inpatient services.

B. Review of the facility policies and procedures lacked evidence of observation patient care and treatment. The facility was unable to provide observation patient care and treatment policies and procedures per REH regulations (that address the post-acute care needs of patients receiving services in the REH). Confirmed during an interview on 9/25/2024 at 3:00PM, the COO attempted to locate the REH facility observation direct patient care policies and procedures, unable to provide onsite.

C. Review of the facility medical staff bylaws lacked evidence of a finalized approved copy. Confirmed by COO 9/24/2024 at 2:48PM.

A Review of the facility medical staff rules and regulations lacked evidence of a finalized approved copy. Confirmed by COO 9/24/2024 at 2:48PM.

D. During an interview on 9/24/2024 at 2:48PM, the COO revealed the medical staff bylaws and rules and regulations are in revision and are utilizing a third party to assist in the process since converting from a CAH to an REH on 1/11/2024.