Eureka Springs Hospital has responded to findings in recent surveys conducted by the Department of Health and Human Services Centers for Medicare & Medicaid Services that a state health department official said could lead to the termination of the hospital’s Medicare agreement.
A Medicare complaint survey was conducted on Nov. 22, according to documents provided to the Times-Echo in response to a request for information.
Among the findings in that survey were that the hospital’s emergency diagnostic laboratory services were not available 24 hours per day and that there were no laboratory staff members or a contract for emergency laboratory services.
“On November 22, 2024 at 2:30 PM the Chief Executive Officer (CEO) was informed there was an Immediate Jeopardy to patient health and safety …” the survey documents say.
The hospital provided an action plan on Nov. 27, the documents say.
“The Immediate Jeopardy was abated with the following plan of correction on 12/03/2024 at 10:30 AM,” the documents say.
The documents cite a response from the hospital, dated Nov. 26.
“Eureka Springs Hospital (ESH) acknowledges the Immediate Jeopardy (IJ) findings related to emergency diagnostic laboratory services identified during the November 21, 2024, inspection,” the hospital response says. “The hospital recognizes the critical need for emergency lab services and the potential adverse outcomes of any delays in treatment due to the lack of 24-hour diagnostic laboratory availability. We take these findings seriously and have taken immediate corrective actions to resolve the identified non-compliance and ensure our laboratory is fully operational to meet the needs of medical emergencies.”
The hospital’s response goes on to say that some test specimens were being collected and processed at Eureka Springs Hospital and then transported “via courier” to Mercy hospital in Berryville.
“During transport, specimens are maintained under appropriate conditions to preserve their integrity for testing,” the hospital’s response says. “Additionally all protected health information (PHI) is handled in compliance with HIPAA standards.”
The hospital’s response says the average turnaround time from collection to results ranged from 1.5 hours to three hours.
Hospital commission chair Kent Turner and commissioner Sandy Martin transported some of the specimens to Berryville.
The hospital’s response adds that the lab has “identified and implemented temporary, fully qualified staff at appropriate numbers/ levels to offer complete staffing beginning Monday, Dec. 1, 2024.”
“The staff ensures additional qualified personnel to cover all necessary shifts and 24-hour laboratory availability,” the hospital’s response says.
The hospital’s response also addresses training requirements for staff and says all necessary training would be completed by Tuesday, Dec. 9.
In conclusion regarding findings related to diagnostic lab services, the hospital’s response says: “Eureka Springs Hospital is taking immediate and comprehensive action to restore full emergency diagnostic laboratory services and prevent any treatment delays. We are committed to ensuring the safety of our patients and have prioritized this matter as a top concern. We anticipate that the laboratory will be fully operation and compliant by December 9, 2024.”
In another lab-related finding, the survey report noted that the hospital did not have a pathologist to oversee the lab and a lab director.
“In an interview with Chief Executive Officer on 11/22/2024 at 8:21 AM, she stated that ‘on 11/21/2024, the previous Pathology group had terminated their contract. We are in the process of making an offer to another pathology group. As of today, we do not have a pathology group or a laboratory director for the laboratory.”
In its response, the hospital says it “is engaging with pathology groups and consulting with the state CLIA office with regard to continued compliance. Until this standard is met, (the hospital) will provide only limited laboratory services.”
‘The patient could die’ The survey report also discussed the potential consequences of a delay in obtaining laboratory results.
“In an interview with the Interim Chief Executive Officer on 11/22/2024 at 8:26 AM, she stated, ‘as of 11/21/2024 at 7:30 AM, the laboratory medical technician and the Registered Nurses in house are doing laboratory blood draws and a courier service is driving them to Berryville Hospital,” the survey report says. “The surveyor asked what would happen if a patient who needed emergent care, that could only be diagnosed through laboratory results, walked in and needed services. She stated, “the laboratory blood work results would not be done in a timely manner.”
The survey report also cites an interview with an unnamed registered nurse.
“(H)e stated, ‘We are drawing laboratory draws on patients and then couriering them to Berryville Hospital because we do not have anyone in the laboratory qualified to run laboratory tests. We have been on trauma diversion since 11/21/2024 at 7:45 a.m.’ The surveyor asked the nurse what they would do if someone walked in having a possible heart attack. He said, ‘we would draw a troponin laboratory blood test, however, by the time the results returned from Berryville Hospital, the patient could die.’ ” Another finding was that the hospital did not have a registered nurse to oversee nursing services. The hospital commission had fired the former chief nursing officer, Jessica Petrino, at a special meeting on Nov. 4. In its response to the finding, the hospital said it has retained a director of nursing.
Nov. 4 survey
The hospital also responded to findings in a separate survey conducted the week of Nov. 4.
Among the findings noted in a report from that survey were that the hospital “failed to maintain food and nutrition services according to the Arkansas State Board of Health Rules for Hospitals,” noting that patient meals were provided by an unnamed restaurant; failed to have adequate infection control and antibiotic stewardship practices; failed to assure nursing staff was checking crash charts; did not have an effective discharge planning process; did not have an established process for prompt resolution of patient grievances; did not maintain a safe, hygienic environment in a housekeeping closet in the Endoscopy department; failed to provide patient-centered, co mp eten cy – b as ed training and education on the use of restraint and seclusion; failed to develop, implement and maintain a facility-wide quality assessment and performance improvement program; failed to provide a mechanism for reporting or tracking and trending adverse events; failed to ensure guidance and oversight for an ongoing Quality Assurance Performance Improvement Program aimed at improving outcomes and mitigating risk to patients and staff; failed to create and maintain policy and procedures for conducting disaster drills and failed to conduct disaster drills for 2023 and 2024.
In its response to that report, the hospital said its policies and procedures regarding dietary and patient meals were reviewed and revised with the the hospital’s dietary consultant and would be reviewed on an ongoing basis and that the hospital would begin serving prepackaged meals to patients on Dec. 9. The hospital also said it has reviewed policies and procedures related to infection control and antibiotic stewardship.
The hospital also reviewed its policies and procedures for monitoring expired supplies and removed expired items from Endoscopy suites, it said in its response to the survey findings, as well as addressing the protocol for ensuring scopes are clean and ready for patient use.
Expired items also were removed from the ER Room, the hospital’s response says, and policies and procedures for crash cart checks, discharge planning and patient grievances were reviewed.
The hospital also addressed housecleaning deficiencies noted in the survey report and assigned all nursing staff to complete training on the use of restraints and seclusion with a deadline of Dec. 20.
In addition, the hospital said it has reviewed and revised policy and procedure for quality assurance and reviewed its patient satisfaction survey process. The hospital said it will ensure that complete chart notes are scanned into patients’ charts in a timely manner and will continue to monitor for compliance.
In addition, the hospital said it will install battery-powered emergency lights on its generator by Dec. 31 and will install an emergency stop switch near the generator by Jan. 31.
The hospital said documentation of disaster drills conducted in 2023 and 2024 were located in the CEO’s office.