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Government reports show chaotic, disorganized scene inside Galesburg Cottage Hospital

CMS found the hospital to be severely understaffed, saying the situation inside the facility poses a serious risk of injury or death for patients and employees.

GALESBURG, Ill. — After weeks of investigating, the Centers for Medicare & Medicaid Services (CMS) say Galesburg Cottage Hospital is severely understaffed and mismanaged, creating an environment that's unsafe for employees or patients.

The hospital was found to be not in compliance with the protocols of the Medicare program. A CMS report now showing CMS investigators concluded the services provided at Cottage pose, "an immediate risk of serious injury, impairment or death." 

Consequently, CMS announced in December that the government would no longer fund Medicare or Medicaid services at Cottage after Jan. 14. Patients receiving follow-up care that began before that termination date can continue to utilize the payments for up to 30 days. 

RELATED: Galesburg Cottage Hospital receives Medicare, Medicaid extension to Jan. 14

CMS conducted four surveys at the hospital from Nov. 19 through Dec. 23. 

News 8 was able to obtain half of the reported findings from investigators, which detail a disorganized and chaotic scene within Cottage. 

According to the report, on June 2, 2021, a patient was unable to receive sustained CPR, due to to a lack of staff. That same patient eventually died. Just a few weeks later, in July, another patient had been admitted for Covid-19. As the individual got sicker, staff rolled in a crash cart, only to find no resuscitation bags on the cart.

CMS investigators would also discover more issues with the carts. During a tour of Cottage on Nov. 16, 2021, the report notes 8 out of 30 twice-a-day crash cart checks had not been completed. Additionally, 4 out of 15 daily cleanings of crash carts and defibrillators had been missed.

But the overarching issue that the reports repeatedly mentioned was a staffing issue. 

From Mar. 1, 2021 to Nov. 17, Cottage laid off 128 employees. A "Hospital Termination List" kept track of how many nurses were let go from each department, reading: 

  • 12 ICU Registered Nurses plus 1
  • 12 Emergency Department Nurses (5 full time nurses and 8 prn nurses employed as of 11/16/21) 
  • 5 Medical Surgical Unit Nurses plus 7 quit (6 full time nurses and 4 prn nurses employed as of 11/16/21)

Consequently, Cottage's ICU had to be temporarily shut down in July, 2021, to allow those nurses to help out in the equally-understaffed Emergency Room.

Then in September, a Cottage Board of Trustees meeting was marked with letters of resignation from the chairman, vice chairman, and another unidentified member. 

By October, minutes from one of the hospital's Medical Executive Committee read, "ICU staff are filling vacancies in the ED. Must go on trauma bypass if one nurse staffed in ED." 

And it's not just nurses that were missing at the facility. Key leadership positions, across multiple departments, were becoming - and staying - vacant. 

Investigators noted there was no chief operating officer, as well as directors for the emergency department, surgical services, nutrition services, materials management, accounting, informational technology, imaging, health information management, case management or an exercise physiologist in the rehabilitation unit.

Interviews from unidentified employees show any managers who were left were tasked with doubling as managers and directors, while also helping out understaffed teams on the floor. 

CMS interviewed one Cottage employee who said, "They (new owners) are cutting key staff that provide patient safety. They fill holes with unqualified people. The Director of Nursing works shifts all the time because there is no coverage. We have a decreased (volume of patients) because we have no staff. We are capped at 6 patients right now. They are just cutting all of our resources." 

That same employee went on to say, "The managers are acting as directors and working the floor and are tasked so heavily." 

There are also details of nurses being pulled from orientations to help cover open shifts, or made to work without proper documentation of their training and required certifications, all because the hospital was so short-staffed.

Over and over again, throughout the report, employees interviewed by CMS allege the root of the problem stems from Cottage's new owner and CEO, Dr. Sanjay Sharma. 

Sharma took over ownership of Cottage in the summer of 2020. He also obtained ownership of Knox Clinic Corporation, a separate business that runs the clinics associated with Cottage. Sharma is also known to own and operate Pontiac General Hospital in Michigan.

After Sharma took over at Cottage, staff say he implemented a new electronic health record system (EHR). Throughout CMS's report, staff note that system as unreliable and glitchy, saying data could not be properly stored and records were often lost or never filed. All of that, they say, contributed to improper billing. 

In an interview with CMS, one employee said, "This new electronic health record does not allow us to capture data. We can get a few raw numbers like the number of admissions but nothing else. We couldn't even bill because the electronic health record couldn't pull codes for billing. Oh yeah and they fired all the coders." 

A spokesperson for CMS told News 8 that all of these findings placed Cottage into immediate jeopardy, and ultimately led to the decision to terminate Medicare and Medicaid funding. 

In response, Cottage Spokesperson, Courtney Bibo, told News 8: 

"Cottage does not agree with these findings as stated and is currently exploring all options to work with regulators and attorneys to remove and/or appeal the decision." 

Find WQAD's full Galesburg Cottage Hospital coverage here.