Skip to main content


High CEO Turnover Cited in Hospital's Temporary ER Closure

By Steven Porter  
   July 22, 2019

An HHS OIG review listed frequent leadership changes and poor transition planning among the major causes of the Indian Health Service hospital's ER closure and repeated findings of immediate jeopardy.

Instability in leadership ranked among the major reasons why an Indian Health Service (IHS) hospital in Rosebud, South Dakota, shuttered its emergency department for more than seven months, according to a Health and Human Services (HHS) Office of Inspector General (OIG) report.

Rosebud Hospital's emergency department was temporarily closed in December 2015 after the Centers for Medicare & Medicaid Services (CMS) cited immediate jeopardy concerns related to patient health and safety. The deficiencies entailed a failure to offer adequate and timely treatment to four patients, including a child with a possible head injury from a car wreck and a woman who delivered a pre-term baby unattended on the emergency department's bathroom floor, according to the HHS OIG report.

Officials and staff from IHS attributed the hospital's deficiencies to long-running problems with staffing, senior leadership, and equipment:

  • Staffing woes: Officials and staff interviewed said Rosebud Hospital has long had a tough time recruiting and retaining enough doctors, nurses, and other clinical staff because the facility is located in a remote area, so the facility often relied on contracted providers who didn't always meet the hospital's needs or standards, according to the HHS OIG report.
  • Leadership turnover: The hospital had a whopping 27 CEOs over the course of nine years—that's an average tenure of four months—according to an IHS official cited in the report. "Many of these CEOs served in an acting capacity and lasted only a few months before they left voluntarily, were fired by IHS, or were removed by a tribal resolution," the report states. "Although many of these CEOs may have initially appeared to be a good fit, several IHS officials indicated that the CEOs often lacked experience and were ill-equipped to fulfill that role."
  • Equipment issues: Surveyors also found serious problems with the emergency department's equipment, including an oxygen leak, troubles with the telephone and call-light systems, and more. Staffers complained that even suction tubes and heart monitors were often broken or insufficient.

With additional help from IHS, Rosebud Hospital instituted a plan of correction and reopened its emergency department in July 2016, fully satisfying CMS in September 2017. But the hospital was again cited with immediate jeopardy deficiencies related to its emergency department in July 2018. The factors contributing to the latest round of problems again included high leadership turnover and insufficient transition planning, according to the HHS OIG report.

To correct the problems at issue in this case, the HHS OIG report recommends that IHS develop and implement a program to recruit, train, and keep clinical and leadership staff at remote hospitals; take steps to ensure that IHS intervenes quickly enough when problems arise; and develop procedures for any future temporary closures of IHS emergency departments.

Just last week, the IHS was among 27 receipients of about $20 million in HHS funding for the Rural Residency Planning and Development Program.

Steven Porter is an associate content manager and Strategy editor for HealthLeaders, a Simplify Compliance brand.


Over nine years, the average tenure of the hospital's CEO was just four months.

The report advises IHS to develop a recruitment program for rural areas.

Get the latest on healthcare leadership in your inbox.