Glenwood Regional Medical Center

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 30364 48051 Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and the overall hospital environment was maintained in such a manner that assured the safety and well-being of patients. This deficient practice is evidenced by: 1) Failed to ensure the beds in Patient Rooms “a” - “p” were maintained on a consistent preventative maintenance schedule; and 2) Failed to ensure elevators #1 - #11 were maintained on a consistent preventative maintenance schedule and in good working condition. Findings: 1) Failed to ensure the beds in Patient Rooms “a” - “p” were maintained on a consistent preventative maintenance schedule A review of hospital policy titled, “Vytal Work Order Process, EOC 09,” with an effective date of 04/01/2026, revealed in part: “POLICY: The HAS Care System hospitals utilize a standardized work order management system to manage all preventative and corrective work order needs. DEFINITIONS: Preventative Maintenance (PM): The act of performing regularly scheduled maintenance activities to help prevent unexpected failure in the future. Maintenance that is proactively performed on an asset with the goal of lessening the likelihood of failure, reducing unexpected downtime, and prolonging its useful life.” Observations during a walk-through of the hospital on 07/13/2026 from 12:00 PM to 4:35 PM revealed the current patient beds located within Patient Rooms “a” - “p” were not up to date on preventative maintenance. Each of these previously mentioned beds had a preventative maintenance (PM) sticker affix to its frame in which indicated, Next PM due 01/26. Per the date of these preventive maintenance stickers, these patient beds were approximately 6 months past due on regularly scheduled maintenance activities. This had the potential to affect the safety and well-being of patients utilizing these patient beds. In an interview 07/13/2026 and present during the walk-through of the hospital, SCNO1 confirmed the above-mentioned findings. In an interview on 07/14/2026 at 4:08 PM, SCNO1 confirmed the patient beds should be on an annual preventative maintenance schedule, and this task should be performed by hospital plant operations personnel. 2) Failed to ensure elevators #1 - #11 were maintained on a consistent preventative maintenance schedule and in good working condition. A review of the binder titled Elevator Log revealed entries for the elevators in the hospital requiring repairs. Review from 01/25 until 12/25 revealed 44 entries for malfunctioning elevators. Further review of 01/26 through 03/26 revealed 10 entries. In an interview with SCNO1 on 07/13/2026 at 12:00 PM, she said elevators 1, 3, 4 and 8 were currently not working. SCNO1 said elevator #8 went directly from the ED to the cath lab and had been broken for a while. In an interview with S13DPO on 7/14/2026 at 9:32 AM., he said it was not normal for elevators to break this often and it was because of a lack of maintenance. S13DPO said Elevator Company “B” put together a plan to repair the elevators in Feburary 2026 and it was sent up to corporate in March 2026. S13DPO said Elevator Company “A” is not returning because of the lack of payment by corporate. S13DPO also said the elevators can’t keep running in their current condition. In an interview with SCNO1 on 07/14/2026 at 1:50 PM, she said Elevator Company “A” had not come back to the hospital since March 2026. SCNO1 said the reason Elevator Company “A” will not come out was because of lack of payment by the hospital. SCNO1 said the only way Elevator Company “A” will come out is if there is an entrapment of a person in the elevator. SCNO1 said Elevator Company “A” will not do any preventative maintenance since March 2026. She said Elevator Company “B” came out to the hospital to do an assessment and recommendation to repair the elevators. SCNO1 said all of the quotes were sent to the corporate office in March 2026, but they had not received a response from corporate.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38777 Based on record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to ensure patients received care in a safe setting as evidenced by failure to ensure S6MD, who was on call, responded to hospital staff and an accepting hospital’s calls to ensure Patient #1, a critical patient, could be transferred as ordered for a higher level of care. The hospital staff failed to notify any other medical provider, administration or medical director that S6MD failed to answer calls related to timely transferring Patient #1 to a higher level of care, when a bed was available. Furthermore, on 03/16/2024 the hospital staff received notice of another available bed. The hospital staff attempted to call S6MD, the physician caring for Patient #1, who was not on call. The hospital staff failed to follow the appropriate process for after hours when there was no in-house physician on call. The hospital staff also failed to notify any other medical provider, administration or medical director of the available bed, resulting in the bed not being available and the patient not being transferred. (See findings under tag A-0144) On 03/27/2024 at 3:18 p.m. an Immediate Jeopardy was called. The Immediate Jeopardy situation was a result of the hospital failing to take immediate action to prevent on call physicians from not responding to calls related to critical patients and not taking immediate action to prevent hospital staff from not notifying any other medical provider, administrator or medical director when an on call physician is not responding to calls related to a critical patient. This lack of action placed all current 68 patients and any other admitted patients at risk. On 03/28/2024 at 9:34 a.m. S2Qual presented a plan for lifting the immediacy of the IJ situation and the plan included the following: Actions: ICU Staff: Immediate training started 3/27/24 at 4:45 pm with the current ICU staff on duty, and oncoming night shift. Training will continue at the change of shifts until all staff have been properly educated which includes: 1) Following the Chain of Command policy when there is not prompt management and resolution to a patient care concern. 2) This notification includes the use of eICU during 7P to 7A shift, as outlined in the policy, “SOS 01Steward eICU Program Scope of Services”. On 3/27/24 a.m. oncoming shift will be educated. Education will include a manual read and sign. All new hires will receive this training and annual training will be assigned. All staff: Immediate training started on 3/27/24 at 4:45 pm to current staff on the following: 3) Following the Chain of Command policy when there is not prompt management and resolution to a patient care concern. Case Management: CM initiated a search for transfer to a higher level of care. EMR review revealed the failure to document communication regarding the transfer to the attending and ICU team. 03/27/2024 PM met with CM weekday staff still in-house and re-educated of the requirements to document delays, obstacles to expected care plan progression. On 03/28/2024 AM will meet with CM weekday staff, and the Case Management Director will review with weekend staff on the next two weekends, in person, with scheduled weekend staff. On 3/27/24 at 6:00 pm the Interim President sent a notice to all employees via email outlining the responsibilities to use the Chain of Command policy to get a more timely response to a patient transfer, despite the time of day and day of the week. Any communication problems, even with an on-call physician should be escalated as required. This includes using technology like eICU, the RL system (hospital’s incident/accident system), our processes such as reports and huddle, and routine escalations to include House Supervisor, department leadership, Administration, CNO/CMO and Administrator on call. The Interim President notified the board chairman 3/27/24 of the findings. At Leadership Huddle on 3/28/24 and ongoing, the Case Management Director will inform the leaders of any pending transfers or barriers to patient care be communicated. Call Schedule: On 3/28/24, the Intensivist call schedule will be revised to provide additional clarification and was distributed to all on-call providers. The CMO discussed on call responsibilities including responding to calls with the attending Intensivist on 3/27/24. On call responsibility training will be sent to the Medical Staff beginning morning of 3/28/24: The medical staff was notified of the chain of command policy regarding communication process between hospital staff and LIPs via email blast of our policy as well as a hard copy mailed to each active member of staff. Direct communication with ED medical director, hospitalists, and intensivists (inclusive of NP and PA LIP) will be carried out by the CMO and COS. The chain of command response will be communicated with Medical Executive Committee and department chairs by presentation at the Medical Executive Committee meeting as well as by email communication. In an interview on 03/28/2024 at 10:20 a.m. S8RN, S9RN, S10RN, S11RN and S12RN were able to speak to the ICU Physician Call Schedule and the appropriate measures to take if a physician on call fails to answer. On 03/28/2024 at 10:52 a.m. the Immediate Jeopardy situation was lifted.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 38777 Based on record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failure to ensure S6MD, who was on call, responded to hospital staff and an accepting hospital’s calls were answered to ensure Patient #1, a critical patient, could be transferred as ordered for a higher level of care. The hospital staff failed to notify any other medical provider, administration or medical director that S6MD failed to answer calls related to timely transferring Patient #1 to a higher level of care, when a bed was available. On 03/16/2024 the hospital staff received notice of another available bed. The hospital staff attempted to call S6MD, the physician caring for Patient #1, who was not on call. The hospital staff failed to follow the appropriate process for after hours when there was no in-house physician on call. The hospital staff also failed to notify any other medical provider, administration or medical director of the available bed, resulting the bed not being available and the patient not being transferred. Findings: A review of the hospital policy titled Admission, Transfer, and Discharge last revised 05/18/2021 revealed in part: II. Transfer A. Generally Each Attending Practitioner must ensure timely, adequate professional care for his or her patients in the Hospital by being continuously available, or by transferring the care of the patient (temporarily or permanently) to a qualified Medical Staff Member with whom prior arrangements have been made. In the even urgent assistance is needed, Hospital personnel must be able to quickly and accurately identify the responsible Medical Staff Member. F. Transfer to Another Medical Facility Patients transfer to another medical facility must be discharged from the Hospital. III. Discharge B. No patient may be discharged without the agreement of the patient’s Attending Practitioner, unless the patient request discharge against medical advice. A review of the hospitals Rules and Regulations of the Medical Staff revealed in part: 1.5 Each Practitioner must assure timely, continuous, and professional care for his patients in the Hospital by being available himself or having available, through his office, an alternate Practitioner with whom prior arrangements have been made and who is a member in good standing on the Medical Staff. Failure of an attending Practitioner to meet these requirements could result in the loss of clinical privileges. A review of the Glenwood Regional Medical Center MD Call schedule revealed S6MD scheduled 03/15/2024 from 7p-7a. In an interview on 3/26/2024 at 3:40 p.m. S2Qual stated the intensivist covers the ICU and verified the Call scheduled above. A review of Patient #1’s Medical Record on 03/27/2024 with S17RN revealed in part: A note dated 3/13/2024 at 3:33 p.m. dictated by S20NP- Plan: She has not been able to make decision about code status, thus remains full code. D/W S6MD. We will initiate transfer to Hospital “d” (pt. agreeable) for severe PHTN and worsening respiratory failure. A Nurses Note dated 03/14/2024 at 8:43 p.m. S13RN documented a conversation with Hospital “c”. Patient update given and Hospital “c” stated they were checking bed availability and will call back with information to move forward. A Nurses Note dated 03/15/2024 at 00:26 a.m. S13RN documented Hospital “c” called stating they have an ICU bed available, but they were going to be sure Patient #1 meets Hospital “c” ICU criteria and call back. A Nurses Note dated 03/15/2024 at 00:58 a.m. S13RN documented Hospital “c” transfer center calls back stating Hospital “c” ICU MD wants to speak with Glenwood Regional Medical Center ICU MD. S6MD cell phone number give. Hospital “c” states they will call S6MD and coordinate. A Nurses Note dated 03/15/2024 at 1:45 a.m. S13RN documented Hospital “c” called and stated they attempted to call S6MD x 2 with no answer. Hospital “c” MD will not admit until he speaks with S6MD. I attempted to call x1 with no answer; message left with call back number to unit and Hospital “c” Transfer Center number. A Nurses Note dated 3/16/2024 at 8:25 p.m. S13RN documented Hospital “a” transfer center called. Stated Hospital “a” still has no bed available, but Hospital “b” is able to take the patient. 8:45 p.m. Hospital “a” called back and stated Hospital “b” MD wants to speak with Glenwood Regional Medical Center Intensivist. Cell phone number given for S6MD. 9:00 p.m. Hospital “a” calls back and states they called S6MD multiple times with no answer, same as pervious nights attempts. Voicemail left. S13RN stated she will try to call from Glenwood Regional Medical Center and call back with any information. S13RN called S6MD x2 with no answer. Message left. In an interview on 3/27/2024 at 10:30 a.m. S17RN, Case Management verified Patient #1’s Medical Record Information. Further review of Patient #1’s Medical Record revealed: Code Sheet 3/22/24- CPR initiated 2213, PEA on monitor, CPR initiated 2214, 1 epi given 2219, pulse check, asystole---1 epi given 2221, pulse check, asystole---death pronounced A Telemedicine Note dated 03/22/2024 at 10:23 p.m., Called to camera in room for code blue. CPR noted to be in progress. 2 cycles of CPR performed with resulting rhythm of PEA. Death pronounced. In an interview on 3/27/2024 at 10:35 a.m. S19RN, Case Management verified S6MD was the MD making rounds on Friday 3/15/2024 morning and the staff nurse mentioned the phone calls and S6MD stated something to the effect that must have been the call I got around 1-1:30 a.m. In an interview on 3/27/2024 at 10:54 a.m. S2Qual stated there is always a house supervisor, administrator always on call and staff should be aware of this. In an interview on 3/27/2024 at 11:09 a.m. S3RN, Director Case Management stated he was made aware on the Friday after the first time S6MD did not answer. He was also made aware on Monday about the second time. S3RN denies being aware of anyone elevating this to other Medical Staff. In an interview on 3/27/2024 at 11:30 p.m. S16MD, Chief Medical Officer and Hospitalist stated the staff should have called the eICU as they are on call after hours. He also stated he was familiar with Patient #1 but not aware of S6MD not answering the calls. S16MD verified S6MD was on call 3/15/2024 and should have answered the calls. In an interview on 03/27/2027 at 12:05 p.m. S4RN stated there is no documentation showing staff are trained on the MD on Call schedule, eICU. She stated they should call the MD on the schedule, call the answering service, during the day use the unit secretary to find a MD, night and day time the house supervisor has availability for every phone number. S4RN stated she was made aware of S6MD not answering the phone several days after the incident. She questioned, if eICU did not want to transfer the patient. The incident was reported by S13RN. S13RN told her the accepting MD said they wanted to speak with the in-house intensivist, S6MD. She verified S6MD was on call the night of 3/15/2024. She also agreed that S6MD should have answered the call. S13RN told her that after S6MD did not answer she documented in the record and was hoping the bed would be available in morning because S6MD is in house between 7:00- 7:30 am; however, the bed was not available later. S4RN denied speaking with S6MD. S4RN stated she mentioned S6MD not answering call to S1Adm. In an interview S1Adm stated he was made aware of the situation and agreed S6MD should have answered the call. In an interview on 03/27/2024 at 1:07 p.m. S4RN verified there has not been any staff or MD training related to the on call issue. In an interview on 03/27/2024 at 1:35 p.m. S6MD denied receiving a call on 03/15/2024 when he was on call. He reviewed the on call schedule and verified he was on call the night of 03/15/2024. In an interview on 03/27/2024 at 2:05 p.m. S2Qual stated she reviewed Patient #1’s medical record and did not see any documentation related to canceling the transfer order. In an interview on 03/27/2024 at 2:35 p.m. S3RN stated he reviewed Patient #1’s medical record and he failed to locate an order to cancel Patient #1’s transfer. In an interview on 03/28/2024 at 7:20 a.m. S13RN and S14RN verified the nurses note dated 03/14/ 2024 through 03/16 2024, noted above. In an interview on 3/28/2024 at 8:26 a.m. S1Adm stated S15MD Steward’s eICU Medical Director stated the eICU MDs are not credentialed to admit or discharge. In order to transfer a patient they must be discharged. In an interview on 03/28/2024 at 9:30 a.m. S7TeleCom provided print out of an outgoing call from the ICU on 03/15/2024 at 1:27 a.m. to S6MD’s cell phone number. In an interview on 03/28/2024 at 11:10 a.m. S4RN, ICU Director verified S6MD’s cell phone number on the print out of outgoing calls from the ICU on 03/15/2024 at 1:27 a.m. In an interview on 03/28/2024 at 9:40 a.m. S1Adm stated that once he and other administration was made aware of the on call issues they failed to immediately implement measures to prevent the incident from happening again.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 38777 Based on record review and interview, the hospital failed to ensure an effective grievance process was in place. This deficient practice is evidenced by: 1) the facility failing to thoroughly identify, investigate and follow the grievance process for 1 patient (Patient #3); and, 2) the facility failing to ensure a patient complaint requiring further investigation was recognized as a grievance for 1 (Patient #2) of 2 (#2, #3) patients reviewed for complaints/grievances in a total patient sample of 3. Findings: Review of the hospital’s grievance policy and procedure hospital policy titled Patient Complaints and Grievances Chapter: Rights and Responsibility Last Revised: 02/21/2023 revealed in part that all verbal or written complaints regarding abuse, neglect, or hospital compliance with CMS requirements are considered grievances. A written complaint is always considered a grievance. As soon as possible, but no later than within two business days of receipt of the grievance, the patient advocate will contact the grievant to obtain additional details of the complaint. The grievance investigation steps and results will be documented on the grievance in the Complaint and Grievance Management System. Further review of the hospital policy revealed a patient grievance is defined as a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or patient’s representative, regarding patient’s quality of care, abuse or neglect, issues related to the hospital’s compliance with the CMS CoP’s or accrediting organization standards, or a Medicare beneficiary billing complaint related to rights and limitations. Patient #3 1) Review of Patient #3’s nurses notes dated 12/29/2023 at 1:45 p.m. revealed that the family called the patient’s nurse to the room because they found an old bloody gauze on the patient’s left wrist that appeared to be from a previous venous lab draw. The patient was diagnosed with a deep vein thrombosis in the left arm and was not supposed to have needle sticks in the left arm. The family requested to speak to the supervisor and the CEO. On 02/29/2024 at 11:10 a.m., interview with Patient’ #3’s nurse, S2RN, revealed that she was aware that Patient #3’s family had complained about an old bloody gauze that was found on the patient’s left wrist. When asked if this had been investigated to determine what had happened, S2RN stated she was not sure but thought the phlebotomist had stuck the patient in the left arm. Review of the grievance log, presented as current, by S1Director of Quality, revealed no grievance related to Patient #3. Interview with S1Director of Quality on 02/29/2024 at 11:45 a.m. revealed that she was unaware of the complaint made by Patient #3’s family on 12/29/2023 regarding the needle stick in the left arm. S1Director of Quality further stated that Patient #3’s family had met with S3CEO last week about several complaints. When asked if these issues had been identified and thoroughly investigated as grievances and followed the hospital’s grievance process, S1Director of Quality stated no. Interview with S3CEO on 02/29/2024 at 2:30 p.m. revealed that Patient #3’s family had made multiple complaints about the patient’s care and he had talked to them multiple times. S3CEO provided the surveyor with an email (dated 02/10/2024) from Patient #3’s family member sent to S3CEO complaining about a nurse’s “temperament” and “demeanor” when talking to the family member on the phone. The email further stated that the nurse failed to update the family member on the patient’s labs or medical status when they called. When asked if these above complaints had been identified as grievances, been thoroughly investigated, and followed the grievance process, S3CEO stated no. S3CEO further stated that looking back, these should have been identified as grievances and the grievance process should have been implemented. Patient #2 2) A review of the complaint and grievance log revealed Patient #2 had an incident dated 11/05/2023, for which a complaint was received on 12/01/2023. The last documented communication from the hospital was 12/04/2023. Patient #2”s daughter stated prior to their mother passing away S4RN called her sister and stated that she saw there was a signed DNR, and the sister said, “No, we revoked that.” Complainant stated that S4RN went on to say “are you sure that is what you want? She may be a vegetable for the rest of her life.” The daughter of the patient said S4RN was insistent and it was troubling for her sister. She stated S4RN even made the comment that it was “not a wise choice.” She also stated that S4RN said they could not go visit Patient #2, and the visiting hours will start at 9:00 am. Patient #2’s daughters felt S4RN was uncaring, dogmatic, and insistent on getting her way. On Friday, 12/01/2023 the hospital followed up with the ICU director, who stated she was not aware of the incident, but that S4RN had resigned. On Monday, 12/04/2023, the hospital followed up with the complainant for resolution. In an interview on 02/29/2024 at 11:45 a.m., S1Director of Quality reviewed the complaint and grievance log and stated this incident was deemed a complaint and not a grievance; therefore, the family was not sent any letter. She also verified the incident was received on 12/01/2023 and the last communication for resolution with Patient #2’s daughter was on 12/04/2023.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to meet the Condition of Participation for Governing Body. The hospital’s governing body failed to provide needed funding to ensure services and supplies within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This deficient practice was evidenced by: 1) failing to ensure that supplies and services provided or performed under contract and vendor agreements were provided in an effective manner as evidenced by failure of the governing body to pay vendors and contracts for supplies required to care for the patients of the hospital. As a result, many vendors placed provision of supplies and services on credit holds and failed to ship supplies. The lack of supplies and services resulted in: a) cancellations and delays in treatment for patients requiring endoscopy, b) cancellations and delays in surgical services, c) cancellations and delays in special procedures, d) refusal of transfer admissions and ED diversions for patients requiring endoscopy and surgical services which required pacemaker supplies, e) failure to obtain specialized equipment for patients with pressure sores, and f) a delay in the discharge of a client who required ambulance services for transportation home (see findings at A-0084) 2) Failing to ensure that patient treatments were not delayed due to inadequate supplies related to credit holds with vendors. As a result, (a) Patients #1, 2, 3 were uable to obtain specialized air loss mattressess recommended to prevent further decline in wound status, (b) Patient #4 was unable to receive angioplasty to a dialysis fistula and (c) Patient #6 had a delay in PEG tube placement (See findings at A-0144) 3) Failing to maintain supplies needed to perform needed procedures and as a result, Patient #4 was unable to receive an ordered angioplasty procedure (See findings at A-0529); Failing to perform preventive maintenance on the bone density machine and the mammogram machine since 2021 (See findings at A-0537); Failing to ensure that radiology staff were checked monthly for radiation exposure as evidenced by no badge checks for radiology staff since October 2023 (See findings at A-0538) 4) Failing to ensure necessary laboratory supplies were maintained to provide adequate laboratory services (See findings at A-0582) 5) Failing to maintain, or have available, supplies for surgical services such as Spine/Orthopedics, Cardiovascular and Endoscopy services. As a result, patient procedures were cancelled or delayed due to lack of available supplies to perform needed procedures. (See findings at A-0941) 6) Failing to ensure its integrated services were properly supplied to provide the patients with appropriate diagnostic and care interventions (See findings at A-1103). As a result of this noncompliance, on 01/30/2024 at 5:00 p.m., S1CEO was informed of the Immediate Jeopardy situation that existed. The lack of supplies caused delays in treatment for surgical patients and patients requiring endoscopy and special procedures. Patients were refused admittance to this hospital due to these lack of services, which were held out to the public as being available.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to meet the Condition of Participation for Patient Rights. Patients were delayed treatment due to inadequate supplies related to credit holds with vendors. As a result, 1) Patients #1, 2, 3 were uable to obtain specialized air loss mattressess recommended to prevent further decline in wound status, 2) Patient #4 was unable to receive angioplasty to a dialysis fistula and 3) Patient #6 had a delay in PEG tube placement (See findings at A-0144).”

“RADIOLOGIC SERVICES CFR(s): 482.26 The hospital must maintain, or have available, diagnostic radiological services. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications. This Condition is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to meet the Condition of Participation for Radiology. This was evidenced by the hospital: 1) Failing to maintain supplies needed to perform needed procedures and as a result, Patient #4 was unable to receive an ordered angioplasty procedure (See findings at A-0529); 2) Failing to perform preventive maintenance on the bone density machine and the mammogram machine since 2021 (See findings at A-0537); 3) Failing to ensure that radiology staff were checked monthly for radiation exposure as evidenced by no badge checks for radiology staff since October 2023 (See findings at A-0538).”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 36293 Based on observation, record review and interview, the hospital failed to meet the Condition of Participation for Laboratory. The hospital failed to ensure necessary laboratory supplies were maintained to provide adequate laboratory services (See findings at A-0582).”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 20310 Based on record review and interview, the hospital failed to meet the Condition of Participation for Surgical Services. The hospital failed to maintain, or have available, supplies for surgical services such as Spine/Orthopedics, Cardiovascular and Endoscopy services. As a result, patient procedures were cancelled or delayed due to lack of available supplies to perform needed procedures. (See findings at A-0941).”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to comply with applicable state regulations. This deficient practice was evidenced by failure of the hospital to use the State’s designated repository (The Louisiana Office of State Police, Bureau of Criminal Identification and Information) for criminal history information pursuant to the laws cited La R.S.15: 575 on the non-licensed personnel prior to employment for 2 of 2 (S12CNA, S13CNA) non-licensed personnel records reviewed. Findings: The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State ’ s designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2 Employers may request criminal history information stored in LACCH in one of three ways: (1) use of the Bureau ’ s Internet Background Check (IBC) website (https://ibc.dps.louisiana.gov/), (2) via Authorized Agents, and (3) submission of applicants ’ fingerprints. Review of the personnel records for S12CNA and S13CNA revealed their criminal background checks were conducted by Company “A.” Review of the Louisiana Office of State Police authorized agencies to perform criminal background checks revealed Company “A” was not an authorized agency. An interview was conducted with S14HR Director on 02/01/2024 at 1:10 p.m. S14HR Director confirmed that the background checks performed for the unlicensed staff at the hospital, including S12CNA and S13CNA, were not from an authorized agency of the Louisiana Office of State Police.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to ensure that supplies and services provided or performed under contract and vendor agreements were provided in an effective manner as evidenced by failure of the governing body to pay vendors and contracts for supplies required to care for the patients of the hospital. As a result, many vendors placed provision of supplies and services on credit holds and failed to ship supplies. The lack of supplies and services resulted in: 1) cancellations and delays in treatment for patients requiring endoscopy, 2) cancellations and delays in surgical services, 3) cancellations and delays in special procedures, 4) refusal of transfer admissions and ED diversions for patients requiring endoscopy and surgical services which required pacemaker supplies, 5) failure to obtain specialized equipment for patients with pressure sores, and 6) a delay in the discharge of a client who required ambulance services for transportation home. Findings: On 01/29/2024 at 8:20 a.m., interview with SF1CEO revealed the hospital has been having issues for several months with obtaining supplies due to accounts payable problems. SF1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients. Further interview with SF1CEO revealed the hospital was currently on GI diversion due to not being able to obtain endoscopy tubing due to vendor credit holds.The hospital declined to accept two patient transfers needing gastrointestinal services over the last 24 hours due to lack of endoscopy tubing. SF1CEO also stated that the hospital was also unable to perform any procedures involving pacemakers due to being on credit hold with the vendor for pacemakers and pacemaker leads. SF1CEO stated two orthopedic surgeries had been canceled the past week due to credit holds with the vendor. 1. On 01/29/2024 at 8:30 a.m., an interview with SF2CNO revealed the hospital had been out of endoscopy tubing for about a week and one patient had a delay in PEG tube placement as a result (Patient #6). Review of Patient #6’s medical record with S18RN revealed the patient was admitted to the hospital on 01/10/2024 with nausea and vomiting and had been unable to keep food down for two weeks. A gastroenterology consult was requested on 01/11/2024 for elevated liver enzymes, and was consulted a second time on 01/19/2024 for PEG tube placement. Patient #6 initially declined the procedure on 01/21/2024, and again on 01/22/2024. On 01/25/2024, the nursing home refused to admit the patient if she didn’t have a PEG tube or was not fully eating or drinking. On 01/26/2024, the patient agreed to the PEG procedure, but was unable to have it done due to lack of endoscopy tubing supplies in the endoscopy department. S18RN revealed that a local gastroenterologist brought supplies to the facility on 01/27/2024 and the PEG procedure was conducted that day. S18RN (who cared for Patient #6) confirmed that the patient’s needed PEG procedure was delayed for one day due to unavailability of endoscopy supplies related to vendor credit holds. 2. On 01/29/2024 at 8:20 a.m., during the opening entrance conference, S1CEO confirmed that the hospital did not currently have pacemaker supplies for cardiovascular surgical procedures due to credit holds, and that they were also on credit hold with the supplier for shoulder implant surgeries. S2CNO confirmed that two shoulder surgeries this week have been canceled at the ambulatory surgery center due to credit holds. She further stated surgical buttons for ENT procedures were unavailable due to vendor holds. On 01/29/2024 at 2:45 p.m., an interview with S10RN/Director of Surgery confirmed that one surgical procedure for a shoulder arthroscopy had been canceled for today and another one canceled for Wednesday at the ambulatory surgery center due to a credit hold with Arthrex, the supplier. She further confirmed that ENT supplies were on vendor hold due to credit issues. She stated that she recently began completing an Incident Report for all canceled surgeries for tracking purposes. Review of incident reports for surgery revealed two shoulder surgeries were canceled 01/25/2024 in OR due to credit hold with Tournier, the implant supplier. On 01/30/2024 at 2:00 p.m., an interview with S17Purchasing confirmed that the following vendors providing supplies for surgical services were currently on credit hold: : Erbe (endo tubing); Zimmer, Stryker, Osteogen, Tournier, Globus, Medtronic, Ulrich, Enovis, Arthrex (orthopedics, spines, implants); Medtronic, Abbott, Boston Scientific (pacemakers and leads for Transcatheter Aortic Valve Replacement); Medline, Medtronic, Boston Scientific (surgical mesh); Medtronic (ENT buttons). On 01/31/2024 at 10:00 a.m., interview with S8MD (Cardiology) confirmed that the hospital was out of pacemakers due to payment issues with the vendor. When asked what would be done if a patient needed an emergency pacemaker, he stated that he could use a temporary pacemaker until the patient was transferred out to another hospital. S8MD stated this could delay treatment for the patient. S8MD further stated that there are other supplies that the cath lab is out of, but there are “workarounds”, stating these “workarounds” are not optimal. S8MD also stated that he had not been paid for his on-call time for October through December 2023. He stated that he informed administration that if he didn’t receive his payment soon, he would not be taking any more call. Review of the daily report for 01/31/2024 revealed 3 of 7 scheduled surgeries were canceled on this day in the OR - two transcatheter aortic valve replacements (TAVR) and one spine; in addition, one case was canceled at the ambulatory surgery center. All four were canceled due to credit hold issues with the vendors. On 02/01/2024 at 2:00 p.m., an interview with S10RN/Director of Surgery confirmed that the above surgeries had been canceled due to unavailable supplies related to vendor hold issues. On 01/31/2024 at 1:35 p.m., an interview with S9MD (Medical Director of Surgical Services) confirmed that last week, he had to cancel two TAVR surgeries that were scheduled for this week that had been on the schedule for 2-3 weeks prior to the scheduled procedures. He confirmed that you can’t do that specific surgery if there is no pacemaker available, and the pacemaker supplies have been on credit hold for a while. S9MD stated he had personally contacted the representative and thought he would be able to get the pacemaker leads, then found out the hospital didn’t have the catheters either, so he had to have the patients go to another hospital to have the surgeries performed. He further stated that it has become a big problem getting the balloons from Medtronic. He stated that he used the last closure device yesterday, and will have to cancel two surgeries for the next week if the hospital does not get anymore delivered soon. Further interview with S9MD revealed that the supply vendors are owed a large amount of money, and they will only bring supplies if the hospital pays up front. He further stated that the OR usually keeps a good supply of all sizes of heart valves on the shelf, but most of them were expired and the Medtronic representative removed them without any replacements. He also stated the vendor Edwards is also on credit hold. On 02/05/2024 at 11:00 a.m., an interview with S10RN/Director of Surgery confirmed that a surgery had been canceled for the coming Friday for an endovascular aneurysm repair (EVAR) due to the vendor representative not supplying a stent for the procedure due to vendor hold issues. She confirmed they still did not have pacemaker supplies available for TAVR procedures. 3. On 01/30/2024 at 12:50 p.m., interview with S4Director of Radiology and S5Special Procedures Tech confirmed that the Special Procedures department was still having issues with obtaining needed supplies. S4Director of Radiology and S5Special Procedures Tech stated that the department was out of left intrajugular dialysis catheters and multiple sizes of angioplasty balloons. S5Special Procedures Tech revealed that in the past week, a physician was unable to perform an angioplasty on Patient #4, who had a clotted dialysis fistula, due to not having the needed supplies due to credit holds with the vendor. Review of the medical record for Patient #4 revealed the patient was admitted to the hospital ICU on 01/23/2024 with diagnoses including ESRD and dyspnea with fluid overload related to missed hemodialysis treatments. Review of the physician orders revealed an order for the patient to have a fistulogram and PTA (angioplasty used to restore blood flow to the fistula) on 01/26/2024. Further review of the medical record revealed that the fistulogram was performed but not the PTA. The record further revealed that the patient had another procedure on 01/26/2024 to insert a temporary hemodialysis catheter to the right groin. On 02/05/2024 at 11:30 a.m., interview with S4Director of Radiology revealed that the physician was unable to perform the PTA on 01/26/2024 due to lack of angioplasty balloons to perform the procedure. As a result, Patient #4 had to have another procedure on 01/26/2024 to insert a temporary hemodialysis catheter so the patient could receive dialysis treatments. S4Director of Radiology confirmed the lack of supplies caused a delay in the patient’s treatment. On 01/31/2024 at 10:30 a.m., an interview was conducted with S6MD (Medical Director of Radiology). S6MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S6MD stated the Special Procedures department is currently out of left sided dialysis catheters and certain sizes of angioplasty balloons. S6MD further stated that they are also running low on biopsy needles of different sizes and bone marrow needles and kits. S6MD stated that being out these supplies delays diagnosis and treatment for the patients who are waiting on these procedures. S6MD further stated that there would be stints where the vendors would be paid and supplies would arrive and then the supplies would diminish again. S6MD stated that the hospital cannot go much longer like this and that it will eventually fall like a “house of cards”. 4. Review of the daily report for 01/29/2024 revealed that the hospital declined to accept two patient transfers needing gastrointestinal services over the last 24 hours due to lack of endoscopy tubing. On 01/29/2024 at 4:00 p.m., an interview with S2CNO stated the hospital currently does not have the required endoscope supplies or pacemaker supplies to provide services for patients presenting to the Emergency Department or transfer requests from other facilities because they are on purchasing hold with their suppliers due to lack of payment. Review of the transfer denial records revealed: On 01/28/2024 at 1217, a patient with lower GI bleed was denied transfer due to no GI services. On 01/28/2024 at 1304, a patient with a foreign body ingestion was denied transfer due to no ENT or GI endo services. Review of the daily report for 02/04/2024 revealed one transfer was declined over the past 24 hours for a patient needing an ERCP due to lack of endoscopy tubing needed to conduct the procedure. Review of the transfer denial record revealed: On 02/03/2024 at 1826, a patient with nausea and vomiting needing an ERCP was denied transfer due to no GI services. Review of the daily report for 02/05/2024 revealed one transfer was declined over the past 24 hours for a patient needing gastointestinal evaluation due to unavailability of gastrointestinal services. Review of the transfer denial record revealed: On 02/04/2024 at 2148, a patient needing a GI evaluation was denied transfer due to no GI services. Review of the daily report for 02/04/2024 revealed one transfer was declined for a patient needing an ERCP due to lack of endoscopy tubing needed to conduct the procedure. Review of the daily report for 02/05/2024 revealed one transfer was declined for a patient needing gastrointestinal evaluation due to unavailability of gastrointestinal services. 5. On 01/29/2024 at 10:00 a.m., interview with S2CNO revealed that the company that supplies specialty beds was on credit hold and the hospital was unable to obtain specialty low air loss beds for patients with wounds. Review of the medical record for Patient #1 revealed the patient was admitted on 01/11/2024 with a large wound to the right foot with 3rd and 4th metatarsal exposed. Further review revealed the patient was currently on the ventilator in the ICU. Review of the wound care nurses note dated 01/17/2024 revealed the patient would benefit from a specialty low loss air bed to maintain skin integrity. Review of the medical record for Patient #2 revealed the patient was admitted on 01/14/2024 with diagnoses including sepsis and acute hypoxic respiratory failure. Review of the wound care nurses note dated 01/18/2024 revealed a deep tissue injury with intact blister to the coccyx was identified, measuring 6.0 cm x 6.0 cm. The note revealed the patient was on a standard waffle air mattress overlay. Review of the wound care nurses note dated 01/31/2024 revealed the patient’s pressure injury was now unstageable with drainage, measuring 7.5cm x 13.8cm. The note further stated that the patient would benefit from a low loss specialty bed, but remained on a standard waffle air mattress. Review of the medical record for Patient #3 revealed the patient was admitted on 12/30/2023 with a sacral wound with exposed bone. Further review of the record revealed the patient was on a standard waffle air mattress. On 01/31/2024 at 11:30 a.m., interview with the hospital’s wound care nurse, S7RN, revealed that there were multiple patients in the hospital with pressure sores/wounds (including Patients #1, 2 and 3) who would benefit from a specialized low loss air mattress. S7RN further stated that she is unable to obtain the specialized mattresses for these patients because of a credit hold with the vendor who supplied them. 6. On 01/29/2024 at 10:15 a.m., S2CNO revealed that the local ambulance provider had canceled their contract for transfers of non-emergent patients due to credit hold. Review of the daily reporting form dated 02/02/2024 revealed a patient had discharge orders and required a wheelchair van for transportation home. The ambulance declined the transfer due to credit hold.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to meet the Condition of Participation for Patient Rights. Patients were delayed treatment due to inadequate supplies related to credit holds with vendors. As a result, 1) Patients #1, 2, 3 were unable to obtain specialized air loss mattresses recommended to prevent further decline in wound status, 2) Patient #4 was unable to receive angioplasty of a dialysis fistula and 3) Patient #6 had a delay in PEG tube placement. Findings: Patient #1 Review of the medical record for Patient #1 revealed the patient was admitted on 01/11/2024 with a large wound to the right foot with 3rd and 4th metatarsal exposed. Further review revealed the patient was currently on the ventilator in the ICU. Review of the wound care nurses note dated 01/17/2024 revealed the patient would benefit from a specialty low loss air bed to maintain skin integrity. Patient #2 Review of the medical record for Patient #2 revealed the patient was admitted on 01/14/2024 with diagnoses including sepsis and acute hypoxic respiratory failure. Review of the wound care nurses note dated 01/18/2024 revealed a deep tissue injury with intact blister to the coccyx was identified, measuring 6.0 cm x 6.0 cm. The note revealed the patient was on a standard waffle air mattress overlay. Review of the wound care nurses note dated 01/31/2024 revealed the patient’s pressure injury was now unstageable with drainage, measuring 7.5cm x 13.8cm. The note further stated that the patient would benefit from a low loss specialty bed, but remained on a standard waffle air mattress. Patient #3 Review of the medical record for Patient #3 revealed the patient was admitted on 12/30/2023 with a sacral wound with exposed bone. Further review of the record revealed the patient was on a standard waffle air mattress. On 01/31/2024 at 11:30 a.m., interview with the hospital’s wound care nurse, S7RN, revealed that there were multiple patients in the hospital with pressure sores (including Patients #1, 2 and 3) who would benefit from a specialized low loss air mattress. S7RN further stated that she is unable to obtain the specialized mattresses for these patients because of a credit hold with the vendor who supplied them. Patient #4 On 01/31/2024 at 10:30 a.m., an interview was conducted with S6MD (Medical Director of Radiology). S6MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S6MD stated the Special Procedures department is currently out of left sided dialysis catheters and certain sizes of angioplasty balloons. S6MD further stated that they are also running low on biopsy needles of different sizes and bone marrow needles and kits. S6MD stated that being out these supplies delays diagnosis and treatment for the patients who are waiting on these procedures. Review of the medical record for Patient #4 revealed the patient was admitted to the hospital ICU on 01/23/2024 with diagnoses including ESRD and dyspnea with fluid overload related to missed hemodialysis treatments. Review of the physician orders revealed an order for the patient to have a fistulogram and PTA (angioplasty used to restore blood flow to the fistula) on 01/26/2024. Further review of the medical record revealed that the fistulogram was performed but not the PTA. The record further revealed that the patient had another procedure on 01/26/2024 to insert a temporary hemodialysis catheter to the right groin. On 02/05/2024 at 11:30 a.m., interview with S4Director of Radiology revealed that the physician was unable to perform the PTA on 01/26/2024 due to lack of angioplasty balloons to perform the procedure. As a result, the patient had to have another procedure on 01/26/2024 to insert a temporary hemodialysis catheter so the patient could receive dialysis treatments. S4Director of Radiology confirmed the lack of supplies caused a delay in the patient’s treatment. Patient #6 Review of the medical record with S18RN revealed Patient #6 was admitted to the hospital on 01/10/2024 with nausea and vomiting and had been unable to keep food down for two weeks. A gastroenterology consult was requested on 01/11/2024 for elevated liver enzymes, and was consulted a second time on 01/19/2024 for PEG tube placement. Patient #6 initially declined the procedure on 01/21/2024, and again on 01/22/2024. On 01/25/2024, the nursing home refused to admit the patient if she didn’t have a PEG or was not fully eating or drinking. On 01/26/2024, the patient agreed to the PEG procedure, but was unable to have it done due to lack of endoscopy tubing supplies in the Endoscopy area. On 01/27/2024, a local gastroenterologist brought supplies to the facility and conducted the PEG procedure. S18RN (who cared for the patient on the floor) confirmed that the patient’s needed PEG procedure was delayed for one day due to unavailability of supplies related to vendor credit holds.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 17450 Surveyor: Amburn, Heather Based on record review and interview, the hospital failed to ensure that nurses in the ICU had documented skills checks to ensure competence for 2 of 2 ICU nurses whose personnel files were reviewed (S19RN, S20RN). Findings: Review of the personnel files for S19RN and S20RN revealed they they worked in the ICU. Further review of their files revealed no documented skills check offs to ensure competence with specific skills required in the ICU. On 02/01/2024 at 10:55 a.m., an interview with S21RN/Director of Critical Care confirmed that the above RNs had no documented skills check offs to demonstrate competence with skills specific to the ICU. Further interview with S21RN revealed that none of the nurses working in the ICU had documented evidence of skills competencies.”

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to maintain, or have available, radiologic services according to the needs of the patients as evidenced by failing to ensure adequate supplies for all radiological services held out to the public as provided by the hospital. Findings: On 01/29/2024 at 8:20 a.m., interview with S1CEO revealed the hospital was has been having issues for several months with obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients. On 01/30/2024 at 12:50 p.m., interview with S4Director of Radiology and S5Special Procedures Tech confirmed that the Special Procedures department was still having issues with obtaining needed supplies. S4Director of Radiology and S5Special Procedures Tech stated that the department was out of left intrajugular dialysis catheters and multiple sizes of angioplasty balloons and have been for over a month. S5Special Procedures Tech revealed that in the past week, a physician was unable to perform an angioplasty on Patient #4, who had a clotted dialysis fistula, due to not having the needed supplies due to credit holds with the vendor. On 01/31/2024 at 10:30 a.m., an interview was conducted with S6MD (Medical Director of Radiology). S6MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S6MD stated the Special Procedures department is currently out of left sided dialysis catheters and certain sizes of angioplasty balloons. S6MD further stated the department is also running low on biopsy needles of different sizes and bone marrow needles and kits. S6MD stated that being out these supplies delays diagnosis and treatment for the patients who are waiting on these procedures. S6MD further stated that there would be stints where the vendors would be paid and supplies would arrive and then the supplies would diminish again. S6MD stated that the hospital cannot go much longer like this and that it will eventually fall like a “house of cards”. Review of the medical record for Patient #4 revealed the patient was admitted to the hospital ICU on 01/23/2024 with diagnoses including ESRD and dyspnea with fluid overload related to missed hemodialysis treatments. Review of the physician orders revealed an order for the patient to have a fistulogram and PTA (angioplasty used to restore blood flow to the fistula) on 01/26/2024. Further review of the medical record revealed that the fistulogram was performed but not the PTA. The record further revealed that the patient had another procedure on 01/26/2024 to insert a temporary hemodialysis catheter to the right groin. On 02/05/2024 at 11:30 a.m., interview with S4Director of Radiology revealed that the physician was unable to perform the PTA on 01/26/2024 due to lack of angioplasty balloons to perform the procedure. As a result, Patient #4 had to have another procedure on 01/26/2024 to insert a temporary hemodialysis catheter so the patient could receive dialysis treatments. S4Director of Radiology confirmed the lack of supplies caused a delay in the patient’s treatment.”

“PERIODIC EQUIPMENT MAINTENANCE CFR(s): 482.26(b)(2) Periodic inspection of equipment must be made and hazards identified must be promptly corrected. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that all radiology equipment received periodic inspections as evidenced by failing to perform preventive maintenance on the bone density machine and the mammogram machine since 2021. Findings: Review of the preventive maintenance for all equipment in radiology revealed the last inspection documented for the bone density machine and the mammogram machine was in 2021. On 02/01/2024 at 11:00 a.m., interview with S4Director of Radiology revealed that the manufacturers recommendations indicate that the bone density and mammogram machines should be inspected once per year. S4Director of Radiology confirmed that these machines were used on patients in the hospital but there was no documented evidence they had been inspected since 2021.”

“MONITORING RADIATION EXPOSURE CFR(s): 482.26(b)(3) Radiation workers must be checked periodically, by the use of exposure meters or badge tests, for amount of radiation exposure. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that radiology staff were checked monthly for radiation exposure as evidenced by failing to perform monthly badge checks for radiology staff since October 2023. Findings: Review of the log provided by S4Director of Radiology indicating staff radiation exposure revealed that last check was performed on 10/14/2023. On 02/01/2024 at 11:00 a.m., interview with S4Director of Radiology revealed that hospital policy indicates that staff radiation levels are to be checked monthly per the use of badge tests. Further interview with S4Director of Radiology confirmed that there was no documented evidence that staff badge tests for radiation have been performed since 10/14/2023. S4Director of Radiology further stated that the badges were placed in the outgoing mail, but the vendor who was supposed to sort the mail had not been paid, so the mail was not being sorted and mailed out timely.”

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 36293 Based on record review and interview with laboratory director, the hospital failed to ensure the laboratory supplies necessary were maintained to provide adequate laboratory services. Findings: Review of laboratory records on 01/29/2024 revealed the following tests in which the laboratory was unable to obtain the supplies necessary for testing: T3, PTH, Hepatitis B, Cortisol, Procalicitonin; and, all Cepheid molecular PCR reagents (Streptococcal-A, COVID, COVID/Flu/respiratory syncytial virus combination). In an interview 02/01/2024 at 10:00 a.m., S3Director of Laboratory services stated the laboratory department has been unable to obtain necessary supplies for numerous laboratory services due to vendor hold for non-payment. S3Director stated the laboratory notifies administration and corporate in Dallas when there is a critical need for laboratory supplies but the payment issues are not always resolved, resulting in the laboratory being unable to perform testing required or referencing testing to another laboratory which can delay results.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 17450 36293 Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the side rails of 151 of 278 patient beds. Findings: On 01/29/2024 at 10:45 a.m., observations of unoccupied inpatient rooms with S2CNO revealed the patient beds had non-functional nurse call buttons on the side rails of the beds. The nurse call button on the beds were pressed by the surveyors during the observations and no alert of any type was generated when it was pressed. An interview at that time with S2CNO reported that patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient’s bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family/visitor confusion with having the non-functional nurse call feature available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. S2CNO agreed that having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance. In an interview on 02/01/2024 at 3:30 p.m., S1CEO stated there were a total of 151 patient beds with non-functional nurse call buttons on the side rails of the beds.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by failing to maintain a sanitary environment. Findings: 1. Observations of the hospital’s main campus during the initial tour on 01/29/2024 at 10:45 a.m. with S2CNO revealed the following: - Room a had grime/debris on the upper surfaces of bathroom wall call bell switch. - Room b had grime/debris on the upper surfaces of bathroom wall call bell switch, and brownish streaks on the bathroom wall. - Room c had grime/debris on the pulse oxymetry finger-probe. - Room d had grime/debris covering the ledge over the electrical outlets, the oxygen wall outlets and the suction outlet; food particles on the bedside table; and brown streaks on the privacy curtain adjacent to the patient’s toilet. - A vital signs machine located in the hallway on 6S telemetry had grime and debris covering the base of the machine. - An old shower room in the hallway of 5S telemetry used to store clean equipment had foul sewer odor, with some pieces of equipment uncovered. - Room f had a strong foul odor in the bathroom with a partially covered potty chair inside; room g contained a potty chair that was not covered and a partially used syringe of flush sitting on an uncovered IV pole - Room h shower stall had a detached shower hose laying on the floor, a partially covered shower chair with the plastic cover pulled back sitting inside the shower, an uncovered potty chair in the bathroom, and a plastic cap laying in the sink - Room i contained an uncovered IV pole - Room j had a used roll of tape in the window sill, red splatters on the wall and an old dried grape on the floor beside the bedside chair - Room k had a blue sticky substance on the side rails, a syringe behind the chair and 2 bugs were observed crawling on the wall behind the bed - Room l had old tape on the side rails and a red substance splattered across the window blinds - Room m had a brown substance on the overbed table, thick build-up of dust on the window sill and two needle caps on the floor. An interview at this time with S2CNO confirmed the above rooms were considered to be cleaned and ready for a new admit. She further confirmed that clean equipment should be covered. 2. Observations in the OR on 01/29/2024 at 1:20 p.m. with S10RN/Director of Surgery revealed the following: - The anesthesia cart in the hybrid room had multiple black hairs on it. Further observations revealed multiple black hairs on the floor of the OR suite. Interview with S10RN at that time revealed the room had been cleaned. - The foam cover on the table in the cysto room had multiple tears in it, and was unable to be adequately disinfected. The foam leg holders also had tears in it. Interview with S10RN at that time confirmed that the foam covers needed to be replaced, but there were financial issues with the vendor who supplies them. 3. Observations of the offsite Behavioral Health unit with S2CNO and S22Psych Director on 1/30/2024 beginning at 8:15 a.m. revealed the following: - Room e had grime and debris on floor around and under the bed; and the return air vent in ceiling was completely covered in a thick layer of dust/debris - Room n had thick build up of grime and debris in all corners of the room and a screw in the floor - Room o had thick build up of dirt and grime on the floor and old trash on the floor - Room p had a white substance on the floor behind the bed, dirt and grime in all corners of the room, and old candy paper on the floor - Room q had dirt, grime and old food crumbs on the floor and a fabric pillow on the shelf that was unable to be adequately disinfected - The nourishment room on the geriatric unit had a refrigerator with the temperature measuring 50 degrees farhrenheit. A fast food beverage and a homemade loaf of bread (undated) was in the refrigerator. The freezer contained a staff member’s food container. The temperature log taped to the refrigerator was last documented on 01/27/2024, but log indicated daily temp checks. - The nourishment room on the adult unit revealed multiple spills and splatters on the cabinets and door frame. The drawers containing condiments had multiple food spills and debris in the drawers. - The seclusion room had multiple dead bugs/spiders on the floor. The toilet in the seclusion area was coated in a thick black substance. An interview at this time with S2CNO and S22Psych Director confirmed the above patient rooms were considered to cleaned and ready for a patient admit. They further confirmed the above rooms were in need of further cleaning. 36293 .”

“ORGANIZATION OF SURGICAL SERVICES CFR(s): 482.51(a) The organization of the surgical services must be appropriate to the scope of the services offered. This Standard is not met as evidenced by: 20310 Based on observation, record review and interview, the surgical services provided were not appropriate to the scope of services offered as evidenced by failing to maintain supplies necessary for providing the surgical services offered. Findings: On 01/29/2024 at 8:20 a.m., during the opening entrance conference, review of the daily report for 01/29/2024 and interview with S1CEO and S2CNO revealed that the hospital declined to accept two patient transfers needing gastrointestinal services over the last 24 hours due to lack of endoscopy tubing related to vendor credit holds. S1CEO confirmed that the hospital did not currently have pacemaker supplies for cardiovascular surgical procedures requiring the availability of a pacemaker due to credit holds, and they were also on credit hold with the supplier for shoulder implant surgeries. S2CNO confirmed that two shoulder surgeries this week have been canceled at the ambulatory surgery center due to credit holds. She further stated surgical buttons for ENT procedures were unavailable due to vendor holds. On 01/29/2024 at 2:45 p.m., an interview with S10RN/Director of Surgery confirmed that one surgical procedure for a shoulder arthroscopy had been canceled for today and another one canceled for Wednesday at the ambulatory surgery center due to a credit hold with Arthrex, the supplier. She further confirmed that ENT supplies were on vendor hold due to credit issues. She stated that she recently began completing an Incident Report for all canceled surgeries for tracking purposes. Review of incident reports for surgery revealed two shoulder surgeries were canceled 01/25/2024 in OR due to credit hold with Tournier, the implant supplier. On 01/30/2024 at 2:00 p.m., an interview with S17Purchasing confirmed that the following vendors providing supplies for surgical services were currently on credit hold: : Erbe (endo tubing); Zimmer, Stryker, Osteogen, Tournier, Globus, Medtronic, Ulrich, Enovis, Arthrex (orthopedics, spines, implants); Medtronic, Abbott, Boston Scientific (pacemakers and leads for Transcatheter Aortic Valve Replacement); Medline, Medtronic, Boston Scientific (surgical mesh); Medtronic (ENT buttons). Review of the daily report for 01/31/2024 revealed 3 of 7 scheduled surgeries were canceled on this day in the OR - two transcatheter aortic valce replacements (TAVR) and one spine; in addition, one case was canceled at the ambulatory surgery center. All four were canceled due to credit hold issues with the vendors. On 02/01/2024 at 2:00 p.m., an interview with S10RN/Director of Surgery confirmed that the above surgeries had been canceled due to unavailable supplies related to vendor hold issues. On 01/31/2024 at 1:35 p.m., an interview with S9MD (Medical Director of Surgical Services) confirmed that last week, he had to cancel two TAVR surgeries that were scheduled for this week that had been on the schedule for 2-3 weeks prior to the scheduled procedures. He confirmed that you can’t do that specific surgery if there is no pacemaker available, and the pacemaker supplies have been on credit hold for a while. S9MD stated he had personally contacted the representative and thought he would be able to get the pacemaker leads, then found out the hospital didn’t have the catheters either, so he had to have the patients go to another hospital to have the surgeries performed. He further stated that it has become a big problem getting the balloons from Medtronic. He stated that he used the last closure device yesterday, and will have to cancel two surgeries for the next week if the hospital does not get anymore delivered. Further interview with S9MD revealed that the vendors are owed a large amount of money, and they will only bring supplies if they pay up front. He further stated they usually keep a good supply of all sizes of heart valves on the shelf, but most of them were expired and the Medtronic representative removed them without any replacements. They will have to call if they have an aortic aneurysm and need a valve. He stated the vendor Edwards is also on credit hold. Review of the daily report for 02/04/2024 revealed one transfer was declined for a patient needing an endoscopic retrograde cholangio pancreatography (ERCP) due to lack of endoscopy tubing needed to conduct the procedure. Review of the daily report for 02/05/2024 revealed one transfer was declined for a patient needing gastointestinal evaluation due to unavailability of gastrointestinal services. On 02/05/2024 at 11:00 a.m., an interview with S10RN/Director of Surgery confirmed that a surgery had been canceled for the coming Friday for an endovascular aneurysm repair (EVAR) due to the vendor representative not supplying a stent for the procedure due to vendor hold issues. She confirmed they still did not have pacemaker supplies available for TAVR procedures. Review of the medical record for Patient #6 and interview with S18RN revealed Patient #6 was admitted to the hospital on 01/10/2024 to 3 North Med/Surg with nausea and vomiting and had been unable to keep food down for two weeks. A gastroenterology consult was requested on 01/11/2024 for elevated liver enzymes, and was consulted a second time on 01/19/2024 for percutaneous endoscopic gastrostomy (PEG) tube placement. Patient #6 initially declined the procedure on 01/21/2024, and again on 01/22/224. On 01/25/2024, the nursing home refused to admit the patient if she didn’t have a PEG or was not fully eating or drinking. On 01/26/2024, the patient agreed to the PEG procedure, but was unable to have it done due to lack of endoscopy tubing supplies in the Endoscopy area. On 01/27/2024, a local gastroenterologist brought supplies to the facility and conducted the PEG procedure. S18RN, confirmed that the patient’s needed PEG procedure was delayed for one day due to unavailability of supplies related to vendor credit holds.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 36293 Based on record review and administrative interview, the hospital failed to ensure its integrated services were properly supplied to provide its patients with appropriate diagnostic and care interventions. This deficient practice was evidenced by the hospital failing to have the required endoscope and pacemaker supplies to prevent the unnecessary transfer and diversion of patients from their emergency department. Findings: On 01/29/2024 at 8:20 a.m., during the opening entrance conference, review of the daily report for 01/29/2024 and interview with S1CEO and S2CNO revealed that the hospital declined to accept two patient transfers needing gastrointestinal services over the last 24 hours due to lack of endoscopy tubing related to vendor credit holds. S1CEO further revealed that the hospital did not currently have pacemaker supplies for cardiovascular surgical procedures due to credit holds, and patients needing those services would also be diverted to another hospital. On 01/29/2024 at 4:00 p.m., an interview with S2CNO stated the hospital currently does not have the required endoscope supplies or pacemaker supplies to provide services for patients presenting to the Emergency Department because they are on purchasing hold with their suppliers due to lack of payment. Review of the transfer denial records revealed: On 01/28/2024 at 1217, a patient with lower GI bleed was denied transfer due to no GI services. On 01/28/2024 at 1304, a patient with a foreign body ingestion was denied transfer due to no ENT or GI endo services. Review of the daily report for 02/04/2024 revealed one transfer was declined over the past 24 hours for a patient needing an ERCP due to lack of endoscopy tubing needed to conduct the procedure. Review of the transfer denial record revealed: On 02/03/2024 at 1826, a patient with nausea and vomiting needing an ERCP was denied transfer due to no GI services. Review of the daily report for 02/05/2024 revealed one transfer was declined over the past 24 hours for a patient needing gastointestinal evaluation due to unavailability of gastrointestinal services. Review of the transfer denial record revealed: On 02/04/2024 at 2148, a patient needing a GI evaluation was denied transfer due to no GI services.”

“Patient Sleeping Room Doors CFR(s): NFPA 101 Patient Sleeping Room Doors Locks on patient sleeping room doors are not permitted unless the key-locking device that restricts access from the corridor does not restrict egress from the patient room, or the locking arrangement is permitted for patient clinical, security or safety needs in accordance with 18.2.2.2.5 or 19.2.2.2.5. 18.2.2.2, 19.2.2.2, TIA 12-4 This Standard is not met as evidenced by: 38723 SPECIAL LOCKING ---EXIT DOORS Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice had the potential to affect 40 of 40 residents. 1 of 10 doors are deficient Findings: During the facility tour and interview with staff on February 1, 2024 revealed that the door to the road had a padlock securing the door. The door shall be permitted using one or more of the three listed options and panic hardware installed as well. When special locking devices are permitted one of three options is required in order to allow free egress for staff and visitors. The three options are: 1. The access code for the keypad is posted at the device, or, 2. The key to the override switch is posted at the device, or, 3. Staff carry a key to the override switch at all times Interview with plant operations manager revealed the facility was not aware that one of the three options is required in order to exit from the building.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 38723 K324 Cooking Facilities Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 277of 277 residents. Findings: During the record review on February 1, 2024 revealed that the semi-annual suppression inspection was past due 1/30/2023. Contractor should be on site 2/12/2024 Interview with plant operations manager revealed the facility was aware the semi-annual inspection was not conducted on the hoop suppression system but the contractor could not perform the inspection until 2/12/2024”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 38723 K345 Fire Alarm System - Testing and Maintenance Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 277 of 277 residents. Findings: During the facility tour and the record review on February 1, 2024 revealed that the annual inspection had not been completed. Interview with plant operations director revealed the facility was aware that the required inspections had not been conducted on the fire alarm system but the earliest the contractor could conduct the inspection was 2/12/2024”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 38723 K353 Sprinkler System - Maintenance and Testing Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect of residents. Findings: During the facility tour on February 1, 2024 revealed that the sprinkler system was past due for annual inspection and the sprinkler system pump had a leak from the packing. Interview with plant operations manager revealed the facility was aware that the annual and/or quarterly inspections had not been conducted on the automatic sprinkler system but the contractor was scheduled to arrive on site 2/12/2024”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 38723 Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not located in required fire barriers, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspection and testing have an understanding of the operating components of the doors. Written records of inspection and testing are maintained and are available for review.18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80). Based on visual observation and record review the facility had the fire doors inspected and repaired some doors. This deficiency has the potential to affect 40 of 40 residents. Findings: During the facility tour and record review on February 1, 2024 revealed that the fire door assemblies were inspected but some doors were repaired under a phase 1 work and the remaining door deficiencies are to be repaired under a phase II. The phase II contract has been received but has not been approved by the facility. The complete fire door report has been filed under the OFSM IMS program under attachments. Interview with plant operations manager revealed the facility was aware of the fire door deficiencies but the facility was unable to pay for all of the fire door repairs so the repair was split up into two phases.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 38723 Based on visual observation the facility failed to assure the med gas inspection deficiencies listed on 12/08/2023 inspection report was repaired per Nfpa 99. This deficiency has the potential to affect 4 of 4 residents. Findings: During the facility tour and records review on February 1, 2024 revealed that the med gas was inspected but the deficiencies were not repaired per Nfpa 99. A list of deficiencies are attached to the OSFM IMS site under attachments. Interview with plant operations manager revealed the facility was aware of the deficiencies of the med gas report but the approval to repair the deficiencies had not been granted by the corporate office.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to meet the Condition of Participation for Governing Body. The hospital’s governing body failed to ensure services within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This deficient practice was evidenced by: The hospital’s governing body failing to effectively carry out the functions of the hospital, as were held out as being available to the public and failing to provide the funding needed by the hospital in order to purchase supplies and maintain staff for services such as surgery, ultrasound, nuclear medicine, cardiac cath lab and dialysis. (See Findings at A-0115, 0528, 0576, 0940, 1025, 1100) As a result of this noncompliance, on 12/08/2023 at 11:00 a.m., S1CEO was informed of the Immediate Jeopardy situation that existed. Patients were denied services and/or delayed treatment due to inadequate staffing and/or supplies. Patients were refused admittance to this hospital and inpatients/ED patients were transferred out to other hospitals due to these lack of services, which were held out to the public as being available. On 12/11/2023 at 10:00 a.m., the hospital provided a plan of removal for the Immediate Jeopardy situation. This plan included: - Shift to shift monitoring of staffing levels in all departments. The house supervisor will notify the senior leader responsible of variance in expected staffing to determine the delivery of safe care. - Senior leadership team will monitor supply levels daily to assure they can meet the needs of the patients. - Daily review of ED transfer logs will be conducted to assure appropriate patient disposition at time of service. - An inventory of critical/needed supplies will be conducted daily and discussed with the Executive Vice President of Materials Management/designee to assure adequate supplies are sourced and onsite. - Daily report to corporate leadership to assure funding is available for all staffing and supply needs of the organization. - All reported concerns from providers and staff both verbal, and via online incident reporting system will be reviewed daily by senior leadership team until all issues are resolved. - The weekly OR schedule will be monitored to assure the supplies are on hand for upcoming cases. On 12/14/2023 at 9:37 p.m., the Immediate Situation was lifted and the deficiencies remain at Condition levels.”

“RADIOLOGIC SERVICES CFR(s): 482.26 The hospital must maintain, or have available, diagnostic radiological services. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications. This Condition is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to meet the Condition of Participation for Radiology. The hospital failed to maintain, or have available, diagnostic radiological services such as ultrasound and heart cath lab. As a result, patients were denied services and/or delayed treatment due to inadequate staffing in these departments and lack of supplies to perform needed procedures. (See findings at A-0529)”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 36293 Based on observation, record review and interview, the hospital failed to meet the Condition of Participation for Laboratory. The hospital failed to ensure emergency laboratory services were available to each patient, and that necessary laboratory supplies were maintained to provide adequate laboratory services (See findings at A-0582 and A-0583).”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 20310 Based on record review and interview, the hospital failed to meet the Condition of Participation for Surgical Services. The hospital failed to maintain, or have available, supplies for surgical services such as Spine/Orthopedics, Urology, and General. As a result, patient procedures were cancelled or delayed due to lack of supplies to perform needed procedures. (See findings at A-0941).”

“NUCLEAR MEDICINE SERVICES CFR(s): 482.53 If the hospital provides nuclear medicine services, those services must meet the needs of the patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to meet the Condition of Participation for Nuclear Medicine. The hospital failed to maintain, or have available, diagnostic nuclear medicine services. As a result, patients were denied services and/or delayed treatment due to inadequate staffing in these departments and lack of supplies to perform needed procedures. (See findings at A-1026)”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to ensure that supplies and services provided or performed under contract and vendor agreements were provided in an effective manner as evidenced by failure of the governing body to pay vendors and contracts for staffing, specialized beds and supplies. As a result, many vendors placed provision of supplies and services on credit holds and failed to ship supplies. Findings: Review of the 2023 Governing Body meeting minutes revealed the following:: - In January 2023, 112 transfers were denied due to staffing; there were 37 lost inpatient surgeries due to transfer denials (staffing); several inpatient vascular cases were canceled due to accounts payable issues - In April 2023, there were transfer denials due to staffing and equipment issues; the C-arm was down causing a decrease in orthopedic surgeries; outpatient cath procedures were down due to the loss of a cardiovascular physician; there were decreases from the prior month in surgeries, cath and endoscopy procedures. Review of a letter dated 04/11/23 to the hospital’s Governing Body from the MEC (Medical Executive Committee), signed by 10 physicians (including S4MD (Chief of Radiology); S5MD (Chief of Cardiology); S7MD (Chief Medical Officer) and S7MD (Chief of Surgery) revealed it included the following: They expressed “deep concern regarding current issues that we strongly feel are hindering our ability to render safe and effective care to patients”. Multiple departments have reported imminent threats from vendors to service lines and/or supply chains critical to providing quality patient care. The letter included specific examples which were: Pathology department - The blood center informed the hospital that they may no longer be able to provide blood products to the facility. Nephrology department - The dialysis provider informed the hospital that they may have to pull hemodialysis services from the facility. Cardiovascular Surgery department - “MANY” vendors informed that they were considering no longer supplying artificial valves, endografts and other cardiovascular supplies. Radiology department - There were limitations in ultrasound , computed tomography, and interventional radiology procedures due to lack of critical supplies and manpower. Each cited long overdue payments as a reason for their considerations. “As a result of non-payment, other departments have already had to limit procedures or deal with limited available operating room times due to lack of supplies. Cardiology has suffered due to limited availability of wires for heart cath procedures. Radiology cited similar concerns regarding lack of availability of suction canisters. For Pulmonology/Critical Care the concern has been ventilators and related supplies. Cardiovascular surgery has been limited by availability of oxygenators and pumps for the heart-lung machines. In addition, specialists from Pulmonology, Cardiology, and Cardiovascular surgery outpatient clinics all report patients expressing concern directly to them that they were fearful or concerned about receiving care at the hospital citing safety concerns due to lack of supplies. This is a strong indication that concerns have also become apparent to the community at large.” “Other serious concerns: several specialists have reported not receiving call pay for some time. There has been a departure of staff citing uncertainty regarding the future direction of the company - this included the ER medical director and a long-time hospitalist. Outpatient primary care providers have transitioned to another clinic, which poses a threat to the outpatient referral base.” There was concern that these and other issues have resulted in a decline in the relationship between the hospital and the community, and a growing distrust from local vendors and the patient population. They felt that the “root of many of these issues is the current corporate practice of not paying vendors in a timely manner”. Review of MEC meetings from May to November, 2023 confirmed that the above concerns continued to be a problem, including professional staff and contracted service withdrawals including physicians, telepsych services, the Long Term Acute Care provider, and the dialysis provider. Several major vendors stopped servicing the hospital, affecting Cardiology and Surgery services. 1. On 12/07/2023 at 2:00 p.m., during the entrance conference with S1CEO and S2CNO, S1CEO reported that the hospital has been having issues for several months with staffing and obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients. S1CEO stated that the hospital is an accredited chest pain hospital but the hospital will be on STEMI diversion on this day from 5:00 p.m. until 7:00 a.m. the next morning due to staffing and supply issues in the heart cath lab. S1CEO confirmed there was a large sign on the front of the hospital indicating that this hospital was an Accredited Chest Pain Hospital. S2CNO stated that the hospital went for several weeks recently without PICC lines, due to credit hold on vendor, and central lines were used instead of PICC lines at that time. S2CNO stated that the central lines increased the risk of infection for these patients. S2CNO further revealed that the hospital’s dialysis supplies had been depleted, but just got a shipment in today. S2CNO stated that the hospital was on credit hold with their dialysis supplier and they had stopped sending supplies, so they had been borrowing from other hospitals. S2CNO further stated that the hospital had not been accepting dialysis patient transfers due to having no supplies and was on dialysis diversion for a few days. 2. On 12/07/2023 at 3:30 p.m., when S3Director of Radiology was asked about issues with supplies, S3 stated that the department is out of IVC filters, clips for mammograms and only has one CT biopsy kit available. S3 stated that mammogram is out of tissue markers and those patients are being referred to another hospital for that service due to lack of supplies. S3 further stated that the specialized pulse oximeter used for sedated patients in the MRI is broken, but is unable to be fixed due to credit hold with the repair company. When asked what is done for patients who have orders for an MRI with sedation, S3 stated they would have to be transferred to another hospital because of the lack of a working pulse oximeter specific for MRI machines. S3 revealed that the radiology department (nuclear medicine) required a quarterly survey by a physicist company on 11/17/2023 to ensure proper dosing, but it was not performed due to non-payment. As a result, the hospital had to stop performing nuclear medicine procedures until the vendor was paid on 11/30/2023. S3 stated that patients who required nuclear medicine testing during that time frame were referred to other hospitals. S3 also stated that the MRI machine door was broken from 10/16/2023 until 11/02/2023. He stated the door could not be repaired due to vendor hold issues. When asked what happened to patients who had orders for MRI during this time frame, S3 stated they would be transferred to other hospitals for that service. S3 further stated that the nuclear medicine department required a quarterly survey by a physicist company on 11/17/2023 to ensure proper dosing, but it was not performed due to non-payment. As a result, the hospital had to stop performing nuclear medicine procedures until the vendor was paid on 11/30/2023. S3 stated that patients who required nuclear medicine testing during that time frame were referred to other hospitals. 3. On 12/08/2023 at 12:45 p.m., an interview was conducted with S4MD (Medical Director of Radiology). S4MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S4MD stated they have ran out of supplies for Special Procedures, such as IVC filters, breast biopsy needles, central lines, dialysis catheters and PICC lines due to credit holds with vendors. He stated there would be stints where the vendors would be paid and supplies would arrive and then the supplies would diminish again. S4MD revealed that two weeks ago, the hospital was unable to utilize nuclear medicine services due to the hospital failing to pay for the state required physicist survey. S4MD stated that patients could not have bone scans and heart or abdomen scans during that time. S4MD revealed that approximately one month ago, the MRI machine broke down for three weeks and it was unable to be repaired during that time due to credit hold with vendor. S4MD also revealed that two weeks ago, the hospital was unable to utilize nuclear medicine services due to the hospital not paying for the physicist survey. S4MD stated that patients could not have bone scans and heart or abdomen scans during that time. S4MD stated that there was no 24/7 ultrasound coverage at the hospital and the staffing company that supplies the ultrasound techs is pulling them out soon due to nonpayment. S4MD compared it to “third world medicine” at the hospital. He further stated that patient care is in jeopardy when a patient needs a filter or a catheter and there are no supplies or staff to perform it. 4. On 12/11/23 at 1:00pm, an interview with S8RN/Director of Surgery revealed that the hospital was unable to provide surgeries for urology and orthopedics due to issues with vendor holds on supplies such as: drapes for robotic surgeries; open ended catheters, loops for TURP (transurethral resection of prostate) procedures, stents, Floseal for urology procedures; marker spheres, Surgiflo and bone saws for orthopedic surgeries. S8RN confirmed that the supplies needed to conduct theses procedures were unavailable and that some surgeries had been cancelled due to the lack of supplies. S8RN further revealed the vendor for the laparoscopes is holding scopes sent out for repair due to payment issues and they are currently down to three scopes - they normally have 10 scopes available. 5. On 12/12/23 at 1:30pm, an interview with S7MD (Chief of Surgery) confirmed there were several vendors that have been on hold beyond 30 days, and surgeries have been cancelled or delayed as a result. S7MD stated the surgical vendors were all placed on hold at about the same time in August or September 2023. S7MD confirmed that surgical services have been cancelled due to lack of robotic drapes and supplies for spines, knees and shoulders. They are doing emergency only now (hips and femurs), and stated the situation is “just tragic.” S7MD stated the only urologist is leaving after next month because he has had to cancel half of his procedures due to supplies not available for TURPs and lithotripsies. Endoscopy and gastroenterology procedures are affected due to supply issues and inability to treat bleeds. General surgeries are affected due to supply issues with mesh and drapes. S7MD further stated the hospital no longer has an ENT or gynecologist. S7MD confirmed he has not provided on-call services for the last 10 days because he has not been paid since 10/31/23. Review of the hospital’s policy for Scope of Services - OR (approved 05/05/22) failed to reveal the types of surgical services provided by the hospital. 6. On 12/07/2023 at 4:30 p.m., interview with S2CNO confirmed that the hospital was on credit hold with the vendor that supplies specialized beds, such as air loss beds and bariatric beds. On 12/14/2023 at 9:10 a.m., observation of Patient #7 revealed that the patient was in an ICU regular bed with a standard waffle overlay. At that time, interview with the patient’s nurse revealed that staff had to remove the patient from his speialized air loss bed last night because the vendor was going to pick up the bed. 7. On 12/08/23 9:15am, an interview with S9Director of Dietary Services revealed two of three dietary department vendors (produce and milk) are on shipping holds due to payment issues. 8. Review of the log for transfers out of the ED dated December 1-5, 2023 10 patients were transferred to other facilities. Further review revealed 3 of the 10 transfers were for dialysis services, which was a service that this hospital offered but did not have supplies to provide. Review of the log for transfer denials for December 1-5, 2023 revealed 4 denials for dialysis patients due to lack of dialysis supplies. Dialysis is a service offered by this hospital. 9. Review of the log for trasfer denials for December 1-5, 2023 revealed 2 patient denials due to lack of bariatric beds. 20310”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that patients recieved care in a safe setting as evidenced by failing to provide needed supplies and staffing for 2 patients who required procedures. As a result, these 2 patients had to be transferred to another hospital for the required procedures, which delayed their treatment (Patient #4, Patient #6). Findings: 1. Review of the medical record for Patient #4 revealed an admission date of 12/05/2023. The patient was taken to surgery on 12/05/2023 to perform aortogram with runoff and stenting of right external iliac artery. Further review of the record revealed documentation dated 12/08/2023 that the patient reported chest pain last night. An EKG was performed which showed ST elevation. Documentation revealed the heart “cath lab was unavailable at this facility therefore we had to emergently transfer patient” to Hospital A for emergent left heart cath. Prior to transfer, the patient was in A-Fib with RVR. Documentation revealed the heart cath was performed and it showed a 90% ostial in-stent restenosis followed by an 80% proximal in-stent restenosis. The patient was then transferred back to the original hospital. On 12/08/2023 at 9:30 a.m., an interview was held with S5MD (Chief of Cardiology/Director of Cath Lab). S5MD stated that Patient #4 was his patient and had to be transferred last night to Hospital A for a heart cath. S5MD stated that the cath lab at this hospital was closed due to having no staff available. S5MD revealed that this transfer was not safe for his patient and he was very stressed over this situation. S5MD further stated that staffing issues started about one year ago and have gotten progressively worse in the last couple of months. S5MD stated there is no weekend and evening coverage for nuclear medicine and ultrasound staffing is not consistently covered. S5MD further stated that he has not gotten his on-call pay for the past three months call schedule and stated other physicians have not been paid either. S5MD further revealed that he frequently transfers patients to out of state hospitals due to lack of beds and staffing at this hospital. 2. Review of the medical record for Patient #6 revealed the patient presented to the ED on 11/30/2023 with complaints of abdominal pain. The initial exam suggested possible holangiocarcinoma. Review of the patient’s medical record revealed documentation dated 11/30/2023 that the patient was sent out for an ERCP due to “unable to proceed with ERCP at this facility secondary to supply shortage”. On 12/12/2023 at 4:10 p.m., interview with S2CNO confirmed that the patient was transferred out to another facility due to lack of supplies to perform the ERCP.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to measure, analyze and track all patient adverse events, staffing and supply issues through the quality assessment and improvement program, as evidenced by failure of the hospital to address incidents involving patient transfers and denials, and departmental issues with staffing and supplies. Findings: 1. Review of the medical record for Patient #4 revealed documentation dated 12/08/2023 that the patient reported chest pain last night. An EKG was performed which showed ST elevation. Documentation revealed the heart “cath lab was unavailable at this facility therefore we had to emergently transfer patient” to Hospital A for emergent left heart cath. Prior to transfer, the patient was in A-Fib with RVR. Documentation revealed the heart cath was performed and it showed a 90% ostial in-stent restenosis followed by an 80% proximal in-stent restenosis. The patient was then transferred back to the original hospital. On 12/08/2023 at 9:30 a.m., an interview was held with S5MD (Chief of Cardiology/Director of Cath Lab). S5MD stated that Patient #4 was his patient and had to be transferred last night to Hospital A for a heart cath. S5MD stated that the cath lab at this hospital was closed due to having no staff available. S5MD revealed that this transfer was not safe for his patient and he was very stressed over this situation. 2. Review of the medical record for Patient #6 revealed the patient presented to the ED on 11/30/2023 with complaints of abdominal pain. The initial exam suggested possible holangiocarcinoma. Review of the patient’s medical record revealed documentation dated 11/30/2023 that the patient was sent out for an ERCP due to “unable to proceed with ERCP at this facility secondary to supply shortage”. On 12/12/2023 at 4:10 p.m., interview with S2CNO confirmed that the patient was transferred out to another facility due to lack of supplies to perform the ERCP. 3. Review of the log for transfers out of the ED dated December 1-5, 2023 revealed 10 patients were transferred to other facilities. Further review revealed 3 of the 10 transfers were for dialysis services, which was a service that this hospital offered but did not have supplies to provide. Review of the log for transfer denials for December 1-5, 2023 revealed 4 denials for dialysis patients due to lack of dialysis supplies. Dialysis is a service offered by this hospital. Review of the log for transfer denials for December 1-5, 2023 revealed 2 patient denials due to lack of bariatric beds. Review of the hospital’s QAPI documentation for 2023 revealed no evidence that patient transfers and denials had been formally measured, analyzed, and/or tracked. Further review revealed no documented evidence that the departmental data included issues related to staffing and supply shortages. On 12/08/2023 at 10:35 a.m., interview with S10Director of QA revealed that she had no knowledge of any adverse patient events recently. She further stated that the last full QA report completed was for the 3rd quarter of 2023 and she had no QA data to report since that time related to patient adverse events. When S10Director of QA was asked is she was aware of the above patient transferred to another hospital for a cath lab procedure which delayed treatment, she stated no. Further interview with S10Director of QA on 12/13/2023 at 3:45 p.m. revealed that there was no departmental tracking and reporting of staffing and supply issues within the QAPI reports. 20310”

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 17450 Based on observation, record review and interview, the hospital failed to maintain, or have available, radiologic services according to the needs of the patients as evidenced by failing to ensure adequate supplies and/or staff coverage for all radiological services held out to the public as provided by the hospital. Findings: On 12/07/2023 at 2:00 p.m., during the entrance conference with S1CEO and S2CNO, S1CEO reported that the hospital has been having issues for several months with staffing and obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients. S1CEO stated that the hospital is an accredited chest pain hospital but the hospital will be on STEMI diversion on this day from 5:00 p.m. until 7:00 a.m. the next morning due to staffing and supply issues in the heart cath lab. S1CEO confirmed there was a large sign on the front of the hospital indicating that this hospital was an Accredited Chest Pain Hospital. Due to the staffing issues, S1CEO stated that many outpatient imaging services have been canceled in order to utilize those staff members in the hospital. S2CNO stated that nuclear medicine services are on a part time basis in the hospital, and there is no on-call staff for nuclear medicine after hours for the current week. S2CNO further stated there will be no ultrasound staff coverage on 12/08/2023 from 1:30 p.m. until 9:00 p.m. and no coverage on 12/09/2023 from 6:00 p.m. until 7:00 a.m. the next morning. S2CNO further stated that as of 12/15/2023, the staffing company that provides ultrasound staff for the hospital stated they will not be providing any more staff after that date due to non-payment. On 12/07/2023 at 3:30 p.m., an interview was conducted with S3Director of Radiology. S3 stated that there is a lack of staffing in all radiology departments. S3 revealed that there is no full time staff in ultrasound, but only one contracted staff. The contracted staff works Monday through Thursdays and will work on call at night occasionally. S3 confirmed the lack of ultrasound coverage on 12/08/2023 from 1:30 p.m. until 9:00 p.m. and no coverage on 12/09/2023 from 6:00 p.m. until 7:00 a.m. the next morning. S3 further stated that there was no nuclear medicine coverage on weekends and there was no nuclear medicine coverage for the current week after the fill-in employee (who works full time in another department) gets off at 12:00 p.m. each day. When asked about issues with supplies for radiology, S3 stated that the department is out of IVC filters, clips for mammograms and only has one CT biopsy kit available. S3 stated that mammogram is out of tissue markers and those patients are being referred to another hospital for that service due to lack of supplies. S3 further stated that the specialized pulse oximeter used for sedated patients in the MRI is broken, but is unable to be fixed due to credit hold with the repair company. When asked what is done for patients who have orders for an MRI with sedation, S3 stated they would have to be transferred to another hospital because of the lack of a working pulse oximeter specific for MRI machines. S3 stated that the radiology department (nuclear medicine) required a quarterly survey by a physicist company on 11/17/2023 to ensure proper dosing, but it was not performed due to non-payment. As a result, the hospital had to stop performing nuclear medicine procedures until the vendor was paid on 11/30/2023. S3 stated that patients who required nuclear medicine testing during that time frame were referred to other hospitals. S3 also stated that the MRI machine door was broken from 10/16/2023 until 11/02/2023. He stated the door could not be repaired due to vendor hold issues. When asked what happened to patients who had orders for MRI during this time frame, S3 stated they would be transferred to other hospitals for that service. On 12/08/2023 at 12:45 p.m., an interview was conducted with S4MD (Medical Director of Radiology). S4MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S4MD stated they have ran out of supplies for Special Procedures, such as IVC filters, breast biopsy needles, central lines, dialysis catheters and PICC lines due to credit holds with vendors. He stated there would be stints where the vendors would be paid and supplies would arrive and then the supplies would diminsh again. S4MD revealed that approximately one month ago, the MRI machine broke down for three weeks and it was unable to be repaired during that time due to credit hold with vendor. S4MD also revealed that two weeks ago, the hospital was unable to utilize nuclear medicine services due to the hospital not paying for the physicist survey. S4MD stated that patients could not have bone scans and heart or abdomen scans during that time. S4MD stated that there was no 24/7 ultrasound coverage at the hospital and the staffing company that supplies the ultrasound techs is pulling them out soon due to nonpayment. S4MD compared it to “third world medicine” at the hospital. He further stated that patient care is in jeopardy when a patient needs a filter or a catheter and there are no supplies or staff to perform it.”

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 36293 Based on observation, record review and interview with laboratory personnel, the hospital failed to ensure the laboratory supplies necessary were maintained to provide adequate laboratory services. Findings: Observation during laboratory tour on December 13, 2023 at 9:30 a.m. revealed the laboratory utilized two Sysmex hematology analyzers in use for patient testing. Direct observation of surveyors identified one bottle remaining of CleanCell reagent required for daily maintenance of Sysmex analyzers. Interview with S12Hematology Supervisor on December 13, 2023 at 10:00 a.m. confirmed only one CleanCell was remaining. S12 further stated the laboratory had been trying to order more CleanCell solution along with many other necessary supplies, and that the laboratory had borrowed some from a sister facility. The laboratory planned to clean the instrument with a 5% bleach solution in the barcoded CleanCell tube until the manufacturer supply was received by the laboratory. Interview with S11Director of Laboratory services and S13Pathologist on December 14, 2023 at 11:00 a.m. revealed the laboratory has been unable to obtain necessary supplies for numerous laboratory services for nearly six months. When the laboratory cannot obtain the supplies necessary for patient testing due to stock and payment issues, the laboratory contacts other third party vendors or borrows from neighboring facilities. S11 and S13 stated the laboratory notifies administration and corporate in Dallas when there is a critical need for laboratory supplies but the payment issues are not always resolved, resulting in the laboratory being unable to perform testing required or referencing testing to another laboratory, delaying results. Review of laboratory records from September 2023 - December 2023 revealed the following tests in which the laboratory was unable to obtain the supplies necessary for testing: culture media (all microbiology cultures resulting in send out for identification and sensitivity), Cepheid PCR reagents (Streptococcal-A A, Methicillin-resistant Staphylococcus aureus, COVID, COVID/Flu/respiratory syncytial virus combination), Procalicitonin, Biomerieux organism ID panels, Verigene blood culture panels, Iron, Cortisol, Lipase, Abbott I-Stat cartridges, ACT, blood culture bottles, Radiometer, Sysmex Flourocell, Hemoglobin A1C, urine drug screen reagents, Urinalysis strips and all reagents, Mueller Hinton media, halogen lamps for chemistry instruments, Immucor blood bank quality control. Further record review of quality control and quality assessment records revealed the laboratory utilized expired quality control material from October 13, 2023 - October 25, 2023 due to a credit hold with the Manufacturer A. The laboratory notified administration and corporate of the critical need and inability to obtain the quality control reagents from the manufacturer prior to their expiration.”

“EMERGENCY LABORATORY SERVICES CFR(s): 482.27(a)(1) Emergency laboratory services must be available 24 hours a day. This Standard is not met as evidenced by: 36293 Based on interview, the hospital failed to ensure emergency laboratory services were available to each patient, should they require these services, 24 hours a day, 7 days a week. This deficient practice was evidenced by the laboratory failing to have the ability to provide for replacement blood products when their current stock is depleted. Findings: Interview on 12/11/2023 at 4:00 p.m. with S11Director Laboratory stated for regular use, our blood supply would last approximately four days. S11 stated they usually order blood every other day and after their delivery on 12/10/2023, the lab was placed on COD (Cash on Delivery) for all blood products. S11 continued to state that they have no current plan or method for paying their supplier’s COD. On 12/11/2023 at 4:20 p.m., interview with S1CEO revealed the hospital had no ability to pay the COD required for blood products. On 12/12/2023 at 12:35 p.m., interview with S11Director Laboratory revealed the COD was still required by their supplier and the hospital has no ability to pay COD. On 12/12/2023 at 1:56 p.m., interview with S1CEO revealed the hospital’s blood supplier still required COD and they currently have no ability to pay COD for blood products.”

“ORGANIZATION OF SURGICAL SERVICES CFR(s): 482.51(a) The organization of the surgical services must be appropriate to the scope of the services offered. This Standard is not met as evidenced by: 20310 Based on observation, record review and interview, the surgical services provided were not appropriate to the scope of services offered as evidenced by failing to maintain supplies necessary for providing the surgical services offered. Findings: Review of the hospital’s policy for Scope of Services - OR (approved 05/05/22) failed to reveal the types of surgical services provided by the hospital. On 12/11/23 at 1:00 p.m., an interview with S8RN/Director of Surgery revealed that the hospital surgical procedures included general, cardiovascular, orthopedic/spine, and urology. S8RN further revealed the OR was unable to provide surgeries for urology and orthopedics due to issues with vendor holds on supplies such as: drapes for robotic surgeries; open ended catheters, loops for TURP procedures, stents, Floseal for urology procedures; marker spheres, Surgiflo and bone saws for orthopedic surgeries. S8RN confirmed that the supplies needed to conduct these procedures were unavailable and that some surgeries had been cancelled due to the lack of supplies. S8RN further revealed the vendor for the laparoscopes is holding scopes sent out for repair due to payment issues and they are currently down to three scopes - they normally have 10 scopes available. On 12/12/23 at 1:30 p.m., an interview with S7MD (Chief of Surgery) confirmed there were several vendors that have been on hold beyond 30 days, and surgeries have been cancelled or delayed as a result, with significant decreases since August or September 2023. These vendors include Cook, Medline and Edwards and they were all placed on hold at about the same time. S7MD further confirmed that surgical services offered by the hospital included ortho/spine, cardiac, vascular and general. Spine and orthopedic procedures have been cancelled due to lack of robotic drapes. S7MD stated the spine surgeons usually have about 40 cases per month and are down to 3-4 procedures per month; no knees and shoulders are being performed due to Stryker vendor on hold. S7MD further stated the OR is doing emergency orthopedics only now (hips and femurs), and stated the situation is “just tragic.” S7MD stated the only urologist is leaving after next month because he has had to cancel half of his procedures due to supplies not being available for TURPs (transurethral resection of prostate) and lithotripsies. Endoscopy and gastroenterology procedures are affected due supply issues and inability to treat bleeds. General surgeries are affected due to supply issues with mesh and drapes. S7MD stated the hospital no longer has an ENT or gynecologist. S7MD confirmed he has not provided on-call services for the last 10 days because he has not been paid since 10/31/23. Review of the OR cancellation list for the last 30 days revealed 25 surgeries were cancelled or delayed. Seven of the procedures cancelled were related to supplies not available due to vendor holds - 3 robotic inguinal hernia repairs; 1 laparoscopic catheter insertion for peritoneal dialysis; 2 lumbar interbody fusions and 1 shoulder arthroplasty reverse.”

“STANDARD TAG FOR NUCLEAR MEDICINE SERVICES CFR(s): 482.53 Standard-level Tag §482.53 Condition of Participation: Nuclear Medicine Services If the hospital provides nuclear medicine services, those services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 17450 Based on interview, the hospital failed to maintain, or have available, nuclear medicine services according to the needs of the patients as evidenced by failing to ensure adequate supplies and/or staff coverage for nuclear medicine services held out to the public as provided by the hospital. Findings: On 12/07/2023 at 2:00 p.m., during the entrance conference with S1CEO and S2CNO, S1CEO reported that the hospital has been having issues for several months with staffing and obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients. S2CNO stated that nuclear medicine services are on a part time basis in the hospital, and there is no on-call staff for nuclear medicine after hours for the current week. On 12/07/2023 at 3:30 p.m., an interview was conducted with S3Director of Radiology. S3 stated that there is a lack of staffing in all radiology departments. S3 stated that there was no nuclear medicine coverage on weekends and there was no nuclear medicine coverage for the current week after the fill-in employee (who works full time in another department) gets off at 12:00 p.m. each day. S3 further stated that the nuclear medicine department required a quarterly survey by a physicist company on 11/17/2023 to ensure proper dosing, but it was not performed due to non-payment. As a result, the hospital had to stop performing nuclear medicine procedures until the vendor was paid on 11/30/2023. S3 stated that patients who required nuclear medicine testing during that time frame were referred to other hospitals. On 12/08/2023 at 12:45 p.m., an interview was conducted with S4MD (Medical Director of Radiology). S4MD revealed that two weeks ago, the hospital was unable to utilize nuclear medicine services due to the hospital not paying for the state required physicist survey. S4MD stated that patients could not have bone scans and heart or abdomen scans during that time. S4MD compared it to “third world medicine” at the hospital. He further stated that patient care is in jeopardy when services such as nuclear medicine is not available for patient diagnosis and treatment.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 17450 Based on administrative interviews, the hospital failed to ensure its integrated services were properly staffed to provide its patients with appropriate diagnostic and care interventions. Findings: On 12/07/2023 at 2:00 p.m., during the entrance conference with S1CEO and S2CNO, S1CEO reported that the hospital has been having issues for several months with staffing and obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients. S1CEO stated that the hospital is an accredited chest pain hospital but the hospital will be on STEMI diversion on this day from 5:00 p.m. until 7:00 a.m. the next morning due to staffing and supply issues in the heart catheter lab. S2CNO stated that nuclear medicine services are on a part time basis in the hospital, and there is no on-call staff for nuclear medicine after hours for the current week. S1CNO further stated there will be no ultrasound staff coverage on 12/08/2023 from 1:30 p.m. until 9:00 p.m. and no coverage on 12/09/2023 from 6:00 p.m. until 7:00 a.m. the next morning. S2CNO further stated that as of 12/15/2023, the staffing company that provides ultrasound staff for the hospital stated they will not be providing any more staff after that date due to non-payment. On 12/07/2023 at 3:30 p.m., an interview was conducted with S3Director of Radiology. S3 stated that there is a lack of staffing in all radiology departments. S3 revealed that there is no full time staff in ultrasound, but only one contracted staff. The contracted staff works Monday through Thursdays and will work on call at night occasionally. S3 confirmed the lack of ultrasound coverage on 12/08/2023 from 1:30 p.m. until 9:00 p.m. and no coverage on 12/09/2023 from 6:00 p.m. until 7:00 a.m. the next morning. On 12/08/2023 at 12:45 p.m., interview with S4MD revealed that there was no 24/7 ultrasound coverage at the hospital and the staffing company that supplies the ultrasound techs is pulling them out soon due to nonpayment. S4MD compared it to “third world medicine” at the hospital. He further stated that patient care is in jeopardy when a patient needs a filter or a catheter and there are no supplies or staff to perform it. S4MD stated that you cannot run an ED without these diagnostic services. Review of the transfer log for the ED for December 1-5, 2023 revealed 10 transfers to other facilities. Further review revealed 3 of the 10 transfers were for dialysis services, which was a service that this hospital offered but did not have supplies to provide. 36293”