HospitalInspections.org

Based on review of facility policy, review of laboratory staffing schedule, review of Emergency Department (ED) Logs, observation, and interview, the facility failed to ensure laboratory supplies and laboratory personnel were provided 24 hours per day during the period of 2/2/2020 -2/5/2020.

The findings include:

Review of the facility's policy titled "Patient Diversion," last revised 3/2018, showed "...When necessary because of a lack of capacity or capability to treat additional patients, diversion status may be initiated...Diversion shall be initiated only after other options to manage high patient volume and acuity have been exhausted and it is determined that diversion is necessary in the interest of patient safety. Individual departments must continuously evaluate resources and patient demand and implement strategies for providing continued full-service to the community and minimizing diversion...The CEO [Chief Executive Officer] will explore all available options to manage patient volume and avoid diversion...In the event of a lack of capacity or capability in a service or department, the CEO will announce the need to go on appropriate diversion status..."

Review of the facility's policy titled "Scope of Services," last revised 8/2019, showed "...Laboratory. Staffed with a minimum of 1 technologist 24/7/365 [24 hours per day/7 days a week/365 days a year]..." The services provided by the laboratory included chemistry, hematology, microbiology, therapeutic drug monitoring, blood bank, mycology, parasitology, general immunology, urinalysis, endocrinology, and toxicology.

Review of the facility's laboratory staffing schedule dated 2/2020 showed revealed there were no laboratory personnel working on the following dates:

2/4/2020 during the day shift (6:00 AM-6:00 PM)
2/6/2020 during the day shift
2/9/2020 during the day shift
2/14/2020 during the day shift
2/20/2020 during the day shift
2/21/2020 during the day shift
2/27/2020 during the day shift
2/28/2020 during the day shift
2/10/2020 during the night shift (6:00 PM-6:00 AM)
2/11/2020 during the night shift
2/24/2020 during the night shift
2/5/2020 during the night shift

Review of the facility's census dated 2/1/2020 - 2/5/2020 showed the following:
*2/1/2020 the ED had 23 patient encounters; 1 patient was transferred to a psychiatric facility; No inpatients
*2/2/2020 the ED had 21 patient encounters; No transfers; No inpatients
*2/3/2020 the ED had 13 patient encounters; 2 patients were transferred; No inpatients
*2/4/2020 the ED had 18 patient encounters; 1 Obstetrical patient was transferred; No inpatients
*2/5/2020 the ED had 4 patient encounters; 2 transfers (Obstetric patient/mother and baby); No inpatients

Observation and interview on 2/4/2020 at 10:26 AM, with the Interim Laboratory Manager, showed no staff was working in the laboratory. The Interim Laboratory Manager stated the laboratory was closed because the facility was unable to complete blood chemistry panels and complete blood counts (CBC) due to the lack of laboratory supplies.

During an interview on 2/4/2020 at 4:22 PM, the Chief Nursing Officer (CNO) stated the ED was on diversion (notification to Emergency Medical Services [EMS] advising them the facility cannot take patients) beginning on 2/2/2020, due to the inability of the facility to perform blood tests. The CNO stated as of 2/3/2020 the Computed Tomography (CT) scanner was not working and the facility was unsure when it would be repaired. The CNO reported the hospital's current census was 1 patient.

During an interview on 2/5/2020 at 9:30 AM, the CNO stated the laboratory was closed on 2/2/2020 from 6:00 AM-6:00 PM and on 2/3/2020 from 6:00 AM until approximately 12:00 PM because of lack of laboratory supplies and was closed on 2/5/2020 because there was no laboratory personnel working. The CNO stated the facility was not providing laboratory services 24 hours per day as outlined in the facility's "Scope of Services."

During an interview on 2/5/2020 at 2:00 PM, the CNO stated the last date the facility admitted an inpatient was 1/30/2020 and the facility remained on ED diversion because of the facility's inability to do laboratory tests.

Based on facility policy review, review of facility scope of practice, observation, and interview, the Governing Body failed to ensure the laboratory was staffed with personnel and failed to ensure adequate laboratory supplies were available to maintain daily operations of the facility.

The findings included:

Refer to A-0576, A-0582, and A-0583.

Based on policy review, review of the laboratory manager's job descriptions, review of laboratory staffing, observation, and interview, the facility failed to ensure adequate laboratory services were provided during the period of 2/2/2020 - 2/5/2020.

The findings included:

Refer to A-0582 and A-0583.

Based on facility policy review, review of the laboratory manager's job description, review of laboratory staffing, observation, and interview, the facility failed to ensure the availability of laboratory staff and laboratory supplies 24 hours per day during the period of 2/2/2020 - 2/5/2020.

The findings include:

Review of the facility's policy titled "Scope of Services," last revised 8/2019, showed "...Laboratory. Staffed with a minimum of 1 technologist 24/7/365 [24 hours per day/7 days a week/365 days a year]..." The services provided by the laboratory included chemistry, hematology, microbiology, therapeutic drug monitoring, blood bank, mycology, parasitology, general immunology, urinalysis, endocrinology, and toxicology.

Review of the facility's job description titled, "Laboratory Manager" last revised 3/2018 showed the laboratory manager's responsibilities included "...Assure the efficient and effective technical operations of the laboratory...Maintain effective staffing through interviews, hiring, evaluation and personnel development...Maintain supply and equipment inventories required for the operation of the laboratory..."

Review of the facility's policy titled "Patient Diversion," last revised 3/2018, showed "...When necessary because of a lack of capacity or capability to treat additional patients, diversion status may be initiated...Diversion shall be initiated only after other options to manage high patient volume and acuity have been exhausted and it is determined that diversion is necessary in the interest of patient safety. Individual departments must continuously evaluate resources and patient demand and implement strategies for providing continued full-service to the community and minimizing diversion...The CEO [Chief Executive Officer] will explore all available options to manage patient volume and avoid diversion...In the event of a lack of capacity or capability in a service or department, the CEO will announce the need to go on appropriate diversion status..."

Review of the facility's laboratory staffing schedule dated 2/2020 showed there were no laboratory personnel working on the following dates:
2/4/2020 during the day shift (6:00 AM-6:00 PM)
2/6/2020 during the day shift
2/9/2020 during the day shift
2/14/2020 during the day shift
2/20/2020 during the day shift
2/21/2020 during the day shift
2/27/2020 during the day shift
2/28/2020 during the day shift
2/10/2020 during the night shift (6:00 PM-6:00 AM)
2/11/2020 during the night shift
2/24/2020 during the night shift
2/5/2020 during the night shift

Observation and interview on 2/4/2020 at 10:26 AM, with the Interim Laboratory Manager, showed no personnel were working in the laboratory and the laboratory did not have the necessary supplies to perform the following laboratory tests:
*Complete Blood Count (CBC - test to evaluate the blood)
*Magnesium Level (electrolyte)
*Phenytoin Level (anticonvulsant)
*Brain Natriuretic Peptide Level (BNP-blood test to indicate heart failure)
*Valporic Acid Level (medication used to treat epilepsy)
The Interim Laboratory Manager stated the facility was unable to complete the laboratory tests because of lack of supplies and the laboratory was currently closed because no laboratory technician was currently working.

During an interview on 2/4/2020 at 12:26 PM, Medical Laboratory Technician (MLT) #1 stated the chemistry machine and the CBC machine had been down since 2/2/2020 due to the lack of laboratory supplies.

During an interview on 2/4/2020 at 4:22 PM, the Chief Nursing Officer (CNO) stated the Emergency Department (ED) was on diversion (notification to EMS advising them the facility cannot take patients) due to the inability of the facility to perform laboratory tests.

During an interview on 2/5/2020 at 9:30 AM, the CNO stated the laboratory was closed on 2/2/2020 from 6:00 AM-6:00 PM and on 2/3/2020 from 6:00 AM until approximately 12:00 PM because of the lack of laboratory supplies and the laboratory was closed on 2/5/2020 because there were no laboratory personnel working. The CNO stated the facility was not providing laboratory services 24 hours per day as outlined in the facility's "Scope of Services."

During an interview on 2/5/2020 at 10:10 AM, the Human Resources Manager stated the previous laboratory manager "...walked out..." on 1/3/2020 and the facility has been without a laboratory manager since that time.

During an interview on 2/5/2020 at 2:00 PM, the CNO stated the ED remained on diversion and the laboratory remained closed.

Based on facility policy review, observation, and interview, the facility failed to provide emergency laboratory services 24 hours per day for 1 Emergency Department (ED) of 1 Emergency Department observed during the period of 2/2/2020 - 2/5/2020.

The findings include:

Review of the facility's policy titled "Scope of Services," last revised 8/2019, showed "...Laboratory. Staffed with a minimum of 1 technologist 24/7/365 [24 hours per day/7 days a week/365 days a year]..." The services provided by the laboratory included chemistry, hematology, microbiology, therapeutic drug monitoring, blood bank, mycology, parasitology, general immunology, urinalysis, endocrinology, and toxicology.

Observation and interview on 2/4/2020 at 10:26 AM, with the Interim Laboratory Manager, showed no staff was working in the laboratory. The Interim Laboratory Manager stated no laboratory technician was working in the laboratory and the laboratory was closed because the laboratory was unable to complete blood chemistry panels and complete blood counts (CBC) due to the lack of laboratory supplies.

During an interview on 2/4/2020 at 4:22 PM, the Chief Nursing Officer (CNO) stated the Emergency Department (ED) was on diversion (notification to Emergency Medical Services advising them the facility cannot take patients) since 2/2/2020 due to the inability of the facility to perform blood tests.

During an interview on 2/5/2020 at 9:30 AM, the CNO stated the laboratory services 24 hours per day as outlined in the facility's "Scope of Services."

During an interview on 2/5/2020 at 2:00 PM, the CNO stated the facility remained on ED diversion because of the facility's inability to perform laboratory tests.