HospitalInspections.org

As directed by the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site focused allegation survey was conducted 10/26/15 through 10/28/15 focusing on the Condition of Participation (COP): Governing Body. The facility was found to be out of compliance with the COP: Governing Body. The severity of the noncompliance had the potential to delay treatment for all patients who came to the facility for emergency services and required inpatient admission for medical evaluation, diagnosis, care and treatment and were not admitted to the facility. The facility transferred patients to other facilities but had the capability to admit and treat those transferred patients

Based on observation, interview, record review, and policy review, the facility's Governing Body failed to ensure the facility admitted 131 patients who came to the ED from 08/01/15 through 10/27/15 for evaluation and required inpatient medical care and were subsequently transferred to other facilities. These failures had the potential to delay treatment and affects all patients who come to the facility and require admission but are not admitted for medical treatment and are transferred. The facility census was 10 psychiatric patients and no (zero) medical patients.

Findings included:

1. Record review of the document titled, "Social Security Act," section 1861(e)(1), showed the following definition: (e) The term hospital means an institution which - (1) is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons.

2. During an interview on 10/26/15 at 11:30 AM, Staff C, Administrator, stated that the facility's Board of Directors (the Board) was ultimately responsible for all operations of the facility and that the Board, by regulatory definition, served as the the facility's Governing Body. She further stated that all documents, references and requirements would recognize the Board functions the same as the CMS regulatory authority of a Governing Body.

3. Record review of the facility's "Bylaws of the Board of Directors", dated 02/26/15, showed:
- The Board was authorized and responsible for control, direction and management of the facility.
- The Board established and approved the Medical Staff Bylaws and Rules/Regulations.
- All medical staff were to adhere to the Medical Staff Bylaws, Rules and Regulations.
- The Board had the responsibility to ensure the philosophy, purpose and objectives of patient services were achieved.

Record review of the facility's "Medical Staff Bylaws" dated 04/23/15, showed the following direction:
- Physician Staff would regularly admit, consult, and perform diagnostic or therapeutic procedures on patients in the hospital.
- Active Medical Staff member(s) admitted patients in accordance with privileges granted by the Board.
- Contractual Medical Staff admitted patients and provided medical services.
- Active Medical Consultant Staff provided consultation upon request of a member of the Active or Courtesy Staff.
The Medical Staff Bylaws provided direction for all Active, Consultant and Contractual Medical Staff to regularly admit and or provide consultation for patients who required medical inpatient care.

During an interview on 10/27/15 at 9:35 AM, Staff B, Board Member and Corporate Chief Nursing Officer (CNO), stated that the only services provided at the facility were emergency services and inpatient psychiatric services. She further stated that "a couple of months ago" physicians were notified that there would be no medical patients admitted to the facility. Patients who were evaluated in the ED and needed an inpatient admission for treatment and/or medical evaluation would be transferred to another facility.

4. Observations made intermittently throughout the on-site survey conducted from 10/26/15 through 10/28/15 of the medical unit showed no inpatients.

During an interview on 10/27/15 at 1:15 PM, Staff K, President and Board member, and Staff M, Board Chairman, stated that the Board:
- Was responsible for the actions of the medical staff and all operations of the facility;
- Merged services with another hospital on or about May 1, 2015 as a result of a change in ownership;
- Notified physicians they could no longer admit medical patients to the facility;
- Informed physicians that patients who presented to the ED and required hospitalization for inpatient care would be transferred to other hospitals;
- Considered the facility an acute care hospital that provided ED services and only admitted patients who needed psychiatric inpatient care and treatment; and
- Made many efforts to advertise and encourage people of the community to come to the facility's ED.

5. During concurrent interview and record review on 10/28/15 at 10:10 AM, of the ED transfer log (a document that listed patients transferred from the facility for inpatient admission) for 08/01/15 through 10/27/15, Staff O, Registered Nurse (RN) Assistant ED Manager, stated that prior to the change of ownership, the facility would have admitted 131 patients that were transferred.

6. During a concurrent record review and interview on 10/27/15 at 11:20 AM, of a
document titled, "Current Practitioner Appointments and Original on Staff Date" dated 09/30/15, Staff H, Manager Risk Management and Regulatory Affairs, showed 81 active Medical Staff members appointed by the Board and approved to admit patients to the hospital. Staff H confirmed the information provided was accurate at the time of review.

During a telephone interview on 10/28/15 at 9:15 AM, Staff J, Internal Medicine Physician and Active Medical Staff, stated, "We don't admit patients for medical services" due to directives he and other physicians received electronically and verbally. He stated that physicians were informed that they could not admit patients other than psychiatric patients to the facility.

7. Record review of written correspondence dated 08/07/15 sent from Staff AA, Assistant Administrator, and addressed to "Colleagues" stated that effective at 12:01 AM on 08/07/15, with the exception of psychiatric patients, the facility would no longer admit medical patients. The correspondence further stated that the only services that would remain at the facility were psychiatric and emergency services and patients that presented to the facility ED and required admission would be transferred and admitted to another facility.

During an interview on 10/28/15 at 12:05 PM, Staff C, Administrator, stated that she did not make the decision to not admit patients and that those decisions were made by the Board. She stated that the facility did not inform the community that the facility no longer admitted patients for general inpatient care. However, the people in the community "just knew ... by word of mouth" that the facility only admitted psychiatric patients. She stated that due to other hospitals not accepting patients, some patients had been transferred far away from the facility.