HospitalInspections.org

Based on facility staff interviews and documentation reviews, the facility failed to ensure compliance with state laws and regulations regarding the availability of required reference Laboratory testing capability essential to the diagnosis and treatment of the patients presenting for emergency services and failed to ensure a current laboratory services contract for four (4) of (4) days of survey.

Findings Include:

During an Interview on 03/10/2025 at 11:03 a.m., the Laboratory Manager confirmed " ...we lost our contract with LabCorp on February 10, 2025 ...".

During an interview on 03/11/2025 at 10:22 a.m., the Chief Executive Officer confirmed " ...no active contract with LabCorp due to nonpayment ...".

During an interview on 03/11/2025 at 12:15 p.m., the Emergency Department Medical Director confirmed we receive emails weekly letting us know ...not available for lab test unable to order. Further confirms we are unable to order urine or blood cultures for our patients.

During an interview on 03/12/2025 at 10:49, the Laboratory Manager confirmed " ...no reference labs are sent out. There is nowhere to send them ... required reference laboratory tests ... include Anticonvulsant and other therapeutic drug level, Cardiac Isoenzymes (including Creatine Kinase-MB), Chloride (Blood and Cerebral Fluid),Methemoglobin, Osmolality, Protein Cerebrospinal Fluid (CSF), CSF and Joint fluid analysis, Sickle Cell prep, Acid Fast Smear/Staining, Chlamydia testing, Counter immune electrophoresis for Bacterial identification, Gram Staining and Culture/Sensitivities, Herpes testing, Streptococcus (Strep) Screening, Viral Culture, Wright Stain, Hepatitis screening, Human Immunodeficiency Virus (HIV) screening, Mononucleosis spot testing."

Review of the facility document titled "Bylaws of the Governing Body" dated November 18, 2018 revealed "Section 2.1 Governing Body ... The Governing Body shall oversee the Hospital's management, operations and compliance with applicable regulations...Section 2.6 ...The Governing Body must be responsible for services furnished in the Hospital ...Section 2.7 ...the hospital must comply with all applicable state and federal regulations ...".

No evidence of a current, signed, dated laboratory contract was submitted for review.

During the exit conference on 03/12/2025 at 10:45 a.m. with the Chief Executive Officer, Director of Nursing, and the Safety Officer survey findings were discussed and no further documentation was provided for review.