HospitalInspections.org

Based on medical record review, CAH policy review, admission packet review, and staff interview, it was determined the CAH failed to ensure compliance with Federal laws and regulations as they related to advance directives and notification an MD/DO was not on-site 24/7 for 31 of 31 patients (#1- #31) whose medical records were reviewed. This had the potential to result in patients and their representatives not being fully informed of their rights for personal decision-making. Findings include:

1. Medical records for Patients #1 - 31 were reviewed. Medical records did not include documentation the hospital's policies related to advance directives were provided to patients or their representatives. The medical records also did not include documentation patients or their representatives were informed in writing that the hospital did not have an MD/DO on site 24/7.

The Compliance Officer was interviewed on 2/07/17, at 11:10 AM. She stated the hospital did not provide written notice to patients the hospital did not have an MD/DO on site 24/7. She stated this information was posted in the registration area. She confirmed they did not specifically document in medical records that advance directive information was provided to patients, but they did document if a patient had an advance directive.

Patients #1 - 31's medical records were incomplete.

2. A CAH policy "Patient Admission," revised 2/10/16, was reviewed. The policy did not address a process to notify patients an MD/DO was not present 24/7 or of the requirement to obtain a signed acknowledgement by the patient of such disclosure.

An admission packet was reviewed. It did not include information which notified patients and their representatives an MD/DO was not present 24/7.

A sign was observed which was posted in the admission registration area. It informed patients an MD/DO was not present in the hospital 24 hours per day, 7 days per week, but rather an experienced RN was present and would call a qualified provider who would be present within 30 minutes.

An individual who worked in Admissions Registration was interviewed on 2/08/17, at 9:00 AM. She stated they did not provide written notice of lack of MD/DO availability, but the information was posted on the wall.

The CAH did not provide written notice (to all inpatients at the beginning of a planned or unplanned inpatient stay and to outpatients for certain types of outpatient visits) an MD/DO was not available 24/7.

3. An admission packet was reviewed and it did not include information related to advance directives.

A CAH policy "Patient Admission," revised 2/10/16, did not address the requirement to advise inpatients or applicable outpatients, or their representatives, of the patient's right to formulate an advance directive and to have CAH staff comply with the advance directive (in accordance with State law). The policy also did not include a clear, precise, and valid statement of limitation for circumstances in which an advance directive would not be implemented. Additionally, the policy did not include a requirement to document when the notice of the CAH's advance directives policy had been provided at the time of admission or registration.

A CAH policy, "Advance Directives," dated 2/09/99, included the following information:

- "Patients or their authorized surrogate decision-makers have the right to issue advance directives to direct the patient's care in the event the patient becomes incompetent.

- Advance directives include (1) Physician's Orders for Scope of Treatment ("POST"); (2) Do Not Resuscitate ("DNR") Orders; (3) Living Wills; (4) Durable Powers of Attorney ("DPOA"); or (5) Other authentic expressions of the patient's wishes concerning their treatment. Upon admission, Caribou Memorial Hospital (CMH) will provide information to patients or their surrogate decision-makers concerning these rights, and will ascertain whether such patients have advance directives.

- Resuscitative measures, including cardiopulmonary resuscitation ("CPR") are presumed unless there is a physician order to the contrary (e.g., a POST, DNR, or verbal order."

The CNO was interviewed on 2/09/17, at 9:10 AM. When asked regarding any limitation to honoring advance directives in the surgical/procedural setting, she stated if a patient had a DNR, they discussed with the patient suspending the DNR during the procedure. There was nothing provided in writing to patients related to limitations in honoring advance directives.

An individual who worked in Admissions Registration was interviewed on 2/08/17, at 9:00 AM. She explained it was her responsibility to register inpatients, outpatients, and patients undergoing observation. She stated she occasionally did registration for the ED, but typically that was done in the ED. She stated they have not been providing advance directive information to patients because the information was not uploaded to the EMR and was not available for printing. She stated they routinely asked patients if they had an advance directive.

The CAH did not advise inpatients or applicable outpatients, or their representatives, of the patient's right to formulate an advance directive and to have CAH staff comply with the advance directive (in accordance with State law). It did not communicate a clear, precise, and valid statement of limitation if the CAH could not implement an advance directive on the basis of conscience, such as an a surgical or procedural area where anesthesia is being used.

Based on observation and staff interview, it was determined the CAH failed to ensure emergency medical equipment was maintained. This resulted in the potential for patients' health and safety to be compromised in the event of a medical emergency. Findings include:

A tour of the ED was conducted with the ED Clinical Coordinator on 2/07/16, beginning at 9:37 AM. The following ED medical equipment had expired:

- Four core temperature probes, expired July 2016.

- Ten IV kit needles, expired July 2016.

- All O2 delivery kits (approximately 20) in the pediatric crash cart, expired March 2016.

- A thoracentesis kit, expired September 2016.

During the tour, the ED Clinical Coordinator stated it was the responsibility of the ED RN to rotate stock to ensure expired equipment was promptly replaced. He confirmed the emergency medical equipment had expired and they were removed from use.

The CAH failed to ensure all emergency medical equipment was maintained.

Based on temperature log review, CAH policy review, and staff interview, it was determined the CAH failed to ensure refrigerator temperature control procedures were established and followed in food preparation areas. This had the potential to interfere with food quality and safety. Findings include:

Refrigerator temperature logs were reviewed for the previous 3 months, for one double-wide refrigerator in the dietary area. The logs included the following "Refrigerated Storage Rules":

"Refrigerated Storage Rules: Temperature must be 38 - 40 degrees & recorded daily before placing any food in it." The form included 4 columns:

- Morning Cook's Initials

- Temperature

- Afternoon Cook's Initials

- Temperature

The form did not provide direction to staff on what to do if the temperature findings were outside of range. Out of range temperatures were documented on the temperature logs for the double-wide refrigerator. The most recent examples follow:

- 2/03/17: 47 degrees

- 2/05/17: 42 degrees

- 2/06/17: 44 degrees

- 2/09/17: 42 degrees

A CAH policy "Food Storage," dated 12/2015, did not include a procedure for follow-up when refrigerator temperatures fell outside of the specified range.

The Dietary Manager was interviewed during a tour on 2/09/17, at approximately 3:00 PM. She stated if a refrigerator temperature was out of range, staff re-checked it. If the temperature improved, they did not document the change in temperature to show it was within range. She stated if the temperature continued to be a problem, they moved food into a larger refrigerated area and contacted maintenance. She confirmed this process was not described on the refrigerator log or in a policy.

The CAH failed to ensure temperature control procedures were established and followed in food preparation areas to ensure proper temperature control of refrigerators.

Based on policy review and staff interview, it was determined the CAH leadership failed to ensure annual review of policies, and to ensure development of a suicide precautions policy. This had the potential to interfere with quality and safety of patient care. Findings include:

1. Refer to C-271 as it relates to the failure of CAH to ensure suicide precautions were provided in accordance with an appropriately written policy.

2. Refer to C-272 as it relates to the failure of CAH leadership to ensure annual review of health care policies.

Based on CAH policy review, CAH procedure review, medical staff rules and regulation review, and staff interview, it was determined the CAH failed to ensure...

1. Refer to C-271 as it relates to the failure of the CAH to ensure suicide precautions were provided in accordance with an appropriately written policy.

2. Refer to C-272 as it relates to the failure of the CAH to ensure annual review of the CAH's health care policies.

3. Refer to C-278 as it relates to the failure of the CAH to ensure a system was established to avoid potential transmission of infections and communicable diseases and a failure to ensure there was a clearly defined and implemented system to identify and investigate infections.

4. Refer to C-283 as it relates to the failure of the CAH to ensure radiation exposure was monitored and measured according to CAH policy and Idaho state regulation.

5. Refer to C-291 as it relates to the failure of the CAH to ensure the list of contracted services described the nature and scope of the services and that the list included non-clinical contracted services.

6. Refer to C-294 as it relates to the failure of the CAH to ensure nursing services met the needs of patients.

7. Refer to C-298 as it relates to the failure of the CAH to ensure nursing care plans were developed and kept current for each inpatient.

8. Refer to C-301 as it relates to the failure of the CAH to ensure a system was established for compiling and retrieving data for quality assurance activities.

9. Refer to C-302 as it relates to the failure of the CAH to ensure medical records contained complete and accurate medical record entries.

The cumulative effect of these negative systematic practices impeded the ability of the CAH to provide services of sufficient scope and quality.

Based on review of medical records, CAH policy review, and staff interview, it was determined the CAH failed to ensure suicide precautions were provided in accordance with an appropriately written policy. This impacted 2 of 2 patients (#11 and #18) identified who required suicide precautions and whose records were reviewed. This resulted in a lack of guidance to staff, inconsistent understanding and practice of implementing suicide precautions, and had the potential to interfere with patient safety. Findings include.

1. A CAH policy "Assessment of Self-Harm," dated 9/01/16, included the following information:

- "The purpose of this policy is to describe the process for assessment for risk and developing a plan of care for patients thirteen years of age or older with suicidal/self-harm/harm of others ideation.

- For patients identified at risk for self-harm, the physician will order the level of needed observation (one to one, line of sight or constant observation) based on patient's level of consciousness and medical condition.

- Documentation reflecting patient's status will be documented in medical record at regular intervals by Nursing.

- While a patient is deemed at risk of self-harm, visitors will be restricted for purposes of confidentiality and safety of patient.

- A safety plan will be developed with the patient. The safety plan shall be reviewed and reiterated with the patient during every interaction until the patient is no longer a suicide risk.

- Once medically stable, patient will be re-evaluated for risk of self-harm by physician and social worker.

- If patient is deemed at continued risk, the physician/social worker will initiate the Behavioral Health Assessment Referral. Social Worker or Case Manager will assist in exploring placement options.

- Upon discharge, a safety plan with community resources, appointment times, etc. will be reviewed and provided to the patient."

The policy did not address essential information. Examples include:

- It did not state how the risk of self-harm would be assessed.

- It did not address or define "suicide precautions."

- It did not define 1:1, line-of-sight, constant observation, or state who was eligible to act in these capacities and what training would be provided.

- It did not address requirements for a safe environment, such as removal of potentially dangerous equipment or items from the room, or placement in a particular room that had been prepared for suicidal patients to ensure safety.

- It did not define a safety plan or provide guidance on how to develop a safety plan.

- It did not address specific documentation requirements, such as frequency or content of documentation or disciplines required to document or updates to the nursing care plan.

As a result of incomplete policy development, staff understanding of requirements varied widely. Several staff were interviewed regarding their understanding of suicide precaution orders and definitions associated with those orders.

a. Staff A, an RN, was interviewed on 2/09/17 at 1:30 PM. She stated she had not had a patient on suicide precautions in a long time and she was not sure of the process. She said she would watch the patient more closely. If a 1:1 was ordered, she stated it would usually be the CNA and she, as an RN, would round hourly, unless needed more often. As far as documentation, she would document the CNA was in the room. She stated the CNA would not document. She stated she was not sure what a safety plan was. She stated she would involve the social worker.

b. Staff B, an RN, was interviewed at 1:45 PM on 2/09/17. She stated she would clear the room of tubing or any objects that could be used to hurt themselves and she would make the room safe. She would contract for safety and round every hour. She stated she was not sure of the current requirements. She stated, if she felt it was necessary, she would increase monitoring to every 15 or every 30 minutes. She stated if a 1:1 was ordered, she was not sure who would stay with the patient. She stated if she did not have someone, she would stay with the patient and try to distract them.

c. Staff C, an RN, was interviewed at 1:30 PM on 2/09/17. When asked what suicide precautions entail, the RN stated it meant a 1:1 "one nurse to patient," removing items the patient could use to harm themselves, and work close with the SW.

d. Staff D, a CNA, was interviewed at 1:37 PM on 2/09/17. When asked what suicide precautions entail, she stated it meant to keep the patient safe by removing items the patient could use to harm themselves, and initiating a 1:1 with the patient. When asked the difference between a 1:1, LOS, and constant observation precaution, the CNA stated a 1:1 was when staff was constantly near the patient, a LOS was when the patient was within eyesight of staff, and constant observation was "like a 1:1." When asked who could perform a 1:1, she stated nurses, "CNA's I assume," physicians if available, and other clinical staff. When asked how suicide precautions were documented, the CNA stated she did not know. When asked who created the safety plan for a suicidal patient, she stated it was the Charge Nurse.

e. The ED Clinical Coordinator was interviewed at 1:41 PM on 2/09/17. When asked what suicide precautions entail, he stated it meant removing items the patient could use to harm themselves, and initiating a 1:1 with the patient "if warranted." When asked the difference between a 1:1, LOS, and constant observation precaution, the ED Clinical Coordinator stated a 1:1 was when dedicated staff were with the patient, a LOS was when the patient was within eyesight of staff, and constant observation was "like LOS, but you could walk away at times." When asked who could perform a 1:1, he stated CNAs or "RNs for overdose or high risk patients." He further stated 1:1 precautions were based on patient risk, acuity, and physician orders. When asked how suicide precautions were documented, the ED Clinical Coordinator stated they were entered into the EMR nurses notes, but only if there was an order. He stated the frequency of documentation would be indicated by physician order. When asked who created the safety plan for a suicidal patient, he stated it "depends on the patient and physician order; it's whatever your comfort zone is."

f. Staff E, an RN, was interviewed at 1:47 PM on 2/09/17. When asked what suicide precautions entail, she stated it meant observing the suicidal patient for safety while in the hospital. When asked the difference between a 1:1, LOS, and constant observation precaution, she stated she did not know. When asked who could perform a 1:1, she stated nurses and CNAs. When asked how suicide precautions were documented, she stated "nurses notes, I think." When asked who created the safety plan for a suicidal patient, she stated she did not know.

g. Staff F, a CNA, was interviewed on 2/09/17, beginning at 1:56 PM. When asked what suicide precautions entail, he stated it meant removing items the patient could use to harm themselves, and initiating a 1:1 with the patient. When asked the difference between a 1:1, LOS, and constant observation precaution, the CNA stated a 1:1 was within the general vicinity of the patient, a LOS was when the staff could see the patient from the doorway of the patient's room, and constant observation was when a nurse had to watch the patient directly in the ICU. When asked who could perform a 1:1, he stated CNAs, nurses, and LPNs. When asked how suicide precautions were documented, the CNA stated they were recorded on a paper observation form every 15 minutes. When asked who created the safety plan for a suicidal patient, the CNA stated it was the nurse. Additionally, he stated he did not know what the safety plan contained.

h. The CNO was interviewed at 2:37 PM on 2/09/17. When asked what suicide precautions entail, the CNO stated it meant a 1:1 with the patient, removing items the patient could use to harm themselves, limit visitors to immediate family, and to remove phones. When asked the difference between a 1:1, LOS, and constant observation precaution, the CNO stated a 1:1 was when staff was "right there" with the patient, a LOS was when the patient was within eyesight of staff, and constant observation was "like a 1:1" as the patient was being observed through a window or live video feed. She stated no patient rooms were currently equipped with live video feed. When asked who could perform a 1:1, the CNO stated clinical staff depending on the type of patient, what the patient did or was planning to do, and that it was dependent on the situation. When asked how suicide precautions were documented, she stated they were recorded on a paper form, the EMR nurses notes, or on a rounding form. When asked who created the safety plan for a suicidal patient, the CNO stated the safety plan and nursing care plan was the same thing. When asked if there was a suicide assessment built in to the EMR for staff to use, she stated there was not.

The CAH failed to ensure suicide precautions were uniformly understood and applied by clinical staff.

2. The following patients were impacted by the lack of a well-developed policy and procedure:

a. Patient #11 was a 15 year old female admitted for observation on 7/06/16, due to an overdose of medication and a suicide attempt.

The physician's admission orders, dated 7/06/16 at 10:45 PM, included orders for suicide precautions.

Patient #11's record included a document titled "SUICIDE WATCH," dated 7/07/16. It stated "DOCUMENT OBSERVATIONS OF PATIENT EVERY FIFTEEN (15) MINUTES." Documentation began every 15 minutes on 7/07/16, at 6:00 AM and continued until 7/08/16, at 9:15 AM, when Patient #11 was discharged.

There was no documentation of observations for over 7 hours, between the time of the order on 7/06/16, at 10:45 PM and 7/07/16, at 6:00 AM.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 10:53 AM. They reviewed Patient #11's record and confirmed documentation was missing for 15 minute checks for over 7 hours. The CNO stated patients were usually put on 1:1 observation when suicide precautions are ordered. She confirmed there were not specific written guidelines for suicide precautions. The CNO stated "it is assumed we watch them closely." She also stated they were aware they needed a suicide precaution policy and that the social worker was working on it.

There was no policy specifically established for suicide precautions. This was confirmed by the Compliance Officer's Assistant on 2/08/17, at 3:25 PM. It was also confirmed by the Social Worker on 2/08/17, at 3:30 PM.

The CAH failed to ensure suicide precaution orders were defined and followed as ordered by Patient #11's physician.

b. Patient #18 was a 13 year old female seen in the ED on 1/20/17, for a suicide attempt. She was admitted to observation status on 1/20/17, and discharged home with family on 1/21/17.

Patient #18's medical record included a "Care Plan," dated 1/20/17, and signed by the RN. The care plan stated "1:1 at all times either family or staff, remove items that could cause harm, provide active listening, assist pt. in finding ways to express self."

Her medical record did not include a physician order for 1:1 suicide precautions. There was no documentation Patient #18 was observed by staff while in the ED or during her observation admission.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM. She confirmed there was no documented order for 1:1 suicide precautions, or documentation of who was watching Patient #18, and when, during her ED and observation stay.

The CAH failed to ensure suicide precautions were provided in accordance with an appropriately written policy.

Based on review of policies, QAPI documentation, and staff interview, it was determined the CAH failed to ensure annual review of the CAH's health care policies. This resulted in outdated policies and had the potential to interfere with quality and safety of patient care. Findings include:

A CAH administrative policy "Annual Evaluation," dated 8/2010, stated the annual review would include a review of all clinical care policies.

A CAH administrative policy, "Policy Management," dated 11/2015, stated "Policies will be reviewed annually and the last review date will be noted. Occasionally a policy may need to be revised more often, for example if new research or federal/state law requires immediate changes. Policies may be updated more often if needed, but will be reviewed at least annually."

Health care policies were not reviewed at least annually, in accordance with CAH policy and federal requirements. Examples of outdated clinical care policies include:

- Patient's Rights, Responsibilities & Grievance Process, last reviewed 3/2000
- Anesthesia - Pre-anesthesia Assessment, last reviewed 4/2010
- Anesthesia - Postoperative Anesthesia Care, last reviewed 4/2010
- Infection Control Program, last reviewed 6/2014
- Infection Control Committee, last reviewed 4/2011
- Infection Control Plan, Last reviewed 6/2013
- Infection Control, Hand Hygiene, last reviewed 9/2013
- ED Triage Policy and Procedure, last reviewed 9/2010
- ED Dead on Arrival, last reviewed 8/2014
- ED Chest Pain, last reviewed 8/2014
- ED Trauma Patient, 10/1981
- Critical & Intensive Care Unit Visitors, last reviewed 7/2014
- Critical & Intensive Care Unit - Nurse Practice Guidelines - Monitoring, last reviewed 7/2014
- Organ & Tissue Donation, last reviewed 1/2004
- Visitation Rights, last reviewed 6/2014
- Pharmacy, last reviewed 1/2012
- Radiation Shielding, last reviewed 1/2000
- Radiation Monitoring, last reviewed 1/2000
- Surgical Services - Sponge, Sharp and Instrument Counts, last reviewed 5/2012
- Surgical Services - Operating the Flash Sterilizer, last reviewed 7/2012

The Compliance Officer was interviewed on 2/08/17 at 8:00 AM. She stated the hospital was currently trying to standardize policies and get caught up on annual review. She stated they were aware of the outdated policies and they had initiated a performance improvement project to update policies and procedures and to standardize the process. She provided information on the PI project which included the following information:

"Date: August 2016
Project Name: "CMH Policy & Contracts
Participants: Dept. Manager, Exec Team
Problem: No standardization (form) of policies, No enforced review dates, No formal review process
Identifier: Each dept. is in charge of their own policies. In review of policies, it was identified that we have duplicate policies and each dept. was using their own headers as well as no formalized review process. This was all identified through interviews with each dept. by myself.
Goal(s): To have all policies & contracts on a controlled program that alerts annual updates with electronic signatures to ensure annual review.

Action Plan:

1. Purchase and implement Hospital Portal with Policy Manager
2. Have all policies submitted to PI dept for standardization
3. Have all contracts submitted to PI dept for cataloging
4. Have all policy [sic] go through a review cycle within the first year
5. Add a provider and midlevel to review of all clinical policies per regulation
6. Have a review cycle for the Board (to be done on a monthly basis for a one year cycle)
7. Have a review cycle for the contracts so they will be automatically come up for annual review.
8. In-service department managers to the Hospital Portal.

Outcome:

1. Standardization of hospital policies and review
2. Annual review process for all contracts"

While the QAPI project addressed the concerns, the process had not sufficiently made progress to ensure annual review of policies.

The CAH failed to ensure health care policies were evaluated annually.

Based on CAH document review, CAH policy review, observation, and staff interview, it was determined the CAH failed to ensure a system to avoid potential transmission of infections and communicable diseases was fully implemented, and failed to ensure systems to identify and investigate infections was clearly defined and implemented. This had the potential to impact all staff and patients in the CAH. Failure to follow policies, nationally recognized guidelines, and standard precautions had the potential to allow for transmission of infections. Findings include:

1. A CAH policy "Infection Control-Infection Control Program," effective 6/11/14, stated "The infection prevention program is comprehensive in that it addresses detection, prevention, and control of infections among patients and personnel. There is ongoing monitoring for infections among patients and personnel and subsequent documentation of infections that occur."

Another CAH policy "Infection Control-Infection Control Plan," effective 6/01/13, stated the purpose of the plan was "To develop and maintain a written plan for infection prevention including an assessment of risk, services provided, the population served, strategies to decrease risk, and a surveillance plan." The policy stated a current written plan will be implemented and guide the activities of the infection prevention department. Additionally, the policy stated the plan will be reviewed at least annually and more often as needed. These policies were not followed.

The current Infection Control Plan was requested and received on 2/07/17. The plan was titled "2017 Infection Control Program" but was not dated and it was not signed.

The ICO was interviewed beginning at 3:20 PM on 2/09/17, the CNO was also in attendance. The ICO stated she recently accepted the position in October 2016. When asked about the 2017 Infection Control Plan the ICO stated the plan was only a draft and was not completed or approved by the Governing Board. The previous plan was requested for review and the ICO stated she did not have one. She stated "It was only one page and I got rid of it after I developed the new one." When asked for data related to tracking of infections the ICO stated she had data which she compiled for review from November 2016, December 2016, and January 2017. When asked about the data collected the ICO stated the infections identified were not tracked or followed up for review. Additionally, she was unaware whether the infection data was part of a quality review.

The ICO stated she received lab reports monthly for review of identified infections however, she confirmed there was no documentation of the data she reviewed from the reports.

During the same interview the CNO stated the previous ICO left employment with the hospital in August 2016. She stated he was under the direction of the CEO. The CNO stated when the current ICO accepted the position she was given any information from the previous ICO. However, the CNO confirmed there was no infection data, no infection plan, and there were no meeting minutes from his tenure as ICO.

The hospital failed to implement a complete IC program.

2. A CAH policy "Nursing-Surgical Services-Operating the Flash Sterilizer (#2)," effective 6/22/09, stated "Use of flash sterilization should be kept to a minimum. Flash sterilization should be used only in selected clinical situations and in a controlled manner." The policy further stated "Flash sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method." The policy referenced the AORN as a guideline.

The AORN Guidelines for Perioperative Practice 2015, stated "Immediate use steam sterilization (IUSS) should be kept to a minimum and should be used only in selected clinical situations and in a controlled manner." Additionally, the AORN Guidelines stated "Immediate use steam sterilization may be associated with increased risk of infection to patients. Time constraints may result in pressure on personnel to eliminate or modify one or more steps in the cleaning and sterilization process."

The CAH policy and AORN guidelines were not followed.

A tour of the CAH's reprocessing area was conducted with a Surgical Technician beginning at 1:30 PM on 2/08/17. During the tour the Surgical Technician was questioned regarding IUSS. She stated 1 autoclave, Sterilizer #2, was used for IUSS and the autoclave was tested daily for proper sterilization temperatures using chemical indicators.

The Surgical Technician stated when instruments were sterilized utilizing IUSS, a chemical strip indicator, was placed in each load. According to the AORN, chemical indicators are used to verify that one or more of the conditions necessary for sterilization were achieved within each package. The IUSS log documented the instruments in the load, the number of the load for that day, and the reason for IUSS, either it was dropped or for quick turn over of the instruments so they may be used for the following procedure. When the instruments were used for a specific patient, on the same day, their name was documented in the log.

The IUSS logs for December 2016, January 2017, and February 2017 were reviewed, and included documentation of IUSS, of surgical instruments, an average of 9 times per month. When the Surgical Technician and OR Clinical Coordinator were asked how frequently surgeries were performed both stated it varied. They stated the OR was scheduled for procedures 1 to 3 times per week and there was 1 to 3 procedures scheduled by surgeons for each day.

IUSS was not used infrequently by the facility. Examples include:

a. On 12/10/16, 12/14/16, 12/26/16, 1/11/17, 1/30/17, 1/31/17, and 2/08/17 the logs documented 2 IUSS loads

b. On 12/19/16 and 1/17/17, the logs documented 5 IUSS loads

When asked about the frequent utilization of IUSS, the Surgical Technician stated IUSS was frequently used for dropped instruments and "turn over" of specific instruments and instrument sets the physicians preferred to use. She stated they were in the process of reviewing purchasing of additional surgical instruments for use in the OR.

The OR Clinical Coordinator confirmed the policy was not followed for infrequent use of IUSS.

The CAH failed to follow their policy and nationally recognized guidelines for infrequent utilization of IUSS.

3. A CAH policy "Droplet Precautions," dated 6/09/99, was reviewed. The policy stated "Change PPE between patients and perform hand hygiene."

An observation of the Medical/Surgical Unit was conducted with the CNO on 2/08/16, beginning at 10:05 AM. During the observation, a patient's room had a droplet precaution sign on the outside of their door and an isolation cart located directly outside their room in the main hallway. A PT and PTA were observed in the patient's room, assisting with therapy. The PT and PTA were in direct contact with the patient and were wearing masks and gloves. The PTA was observed leaving the patient's room twice, while wearing the same pair of gloves, to retrieve items from the isolation cart.

The CNO stated the PT and PTA should have worn disposable gowns since they were within 3 feet of the patient. Additionally, she stated the PTA should have removed her gloves and performed hand hygiene before exiting the patient's room. The CNO confirmed the PT and PTA did not follow the "Droplet Precautions" policy.

The CAH failed to follow their policy and ensure infection prevention precautions were followed.

Based on observation, CAH policy review, and staff interview, it was determined the CAH failed to ensure radiation exposure was monitored and measured according to CAH policy and Idaho state regulation. This had the potential to place personnel at risk for radiation exposure at higher levels which had the potential to place their health and safety at risk. Findings include:

Idaho Radiation Control Rules, IDAPA 16.02.27.004, referenced documents which are used as a means for further clarification of the state rules. One of the publications referenced is "Suggested State Regulations for Control of Radiation, Volume 1," published by the Conference of Radiation Control Program Directors, Inc. The publication stated "Each licensee or registrant shall monitor occupational exposure to radiation from licensed and unlicensed radiation sources under its control and shall supply and require the use of individual monitoring devices." This rule was not followed.

A CAH policy "Radiology-Radiation Monitoring," effective 1/01/00, stated "A film badge shall be worn at all times while performing any radiographic procedure." The policy also stated each employee who works in an area where there is a possibility of radiation exposure will be issued a radiation monitoring badge. This policy was not followed.

An observation was conducted on 2/08/17, beginning at 11:40 AM in the OR suite. The procedure observed was an extraforaminal discectomy (surgical removal of a spinal disc that protrudes to the side) of the lower spine for spinal stenosis (narrowing). During the procedure the surgeon used a fluoroscope. Fluoroscopy is an imaging technique using X-rays to obtain real time moving images as guidance during a procedure. All of the surgical staff, including the surgeon and the CRNA, wore leaded aprons to protect themselves from radiation exposure from the fluoroscope. However, none of the surgical staff, surgeon, or CRNA wore a dosimeter to measure radiation exposure on the outside of their aprons.

During an interview at 1:50 PM on 2/08/17, the OR Clinical Coordinator stated staff do not have or wear dosimeters during procedures with fluoroscopy. She further stated the CAH was not tracking or monitoring radiation exposure levels for surgery staff.

During an interview at 9:15 AM on 2/09/17, the Radiation Technician, who was also the Radiation Officer, was asked about the use of dosimeters in the OR. He stated they do not wear them or measure surgical staff radiation exposure. The Radiation Technician stated he believed this was stopped due to the cost.

The CAH failed to follow their policy and Idaho State Regulations regarding the use of dosimeters and measuring of radiation levels for surgical staff exposed to radiation during procedures in the OR.

Based on a review of a list of contracted services and staff interview, it was determined the CAH failed to ensure the list of contracted services described the nature and scope of CAH services. This list also failed to include non-clinical contracted services. This resulted in an incomplete list of required information and had the potential to interfere with the access of contracted services. Findings include:

A list "CONTRACT PROVIDED SERVICES-2017" included 7 clinically-related contracted services. The list did not include a description of the nature and scope of the services. Further, the list did not include non-clinical contracted services.

The CEO was interviewed on 2/10/17, at 9:25 AM. He confirmed the list did not include non-clinical contracted services or the nature and scope of contracted services.

The CAH failed to ensure the list of contracted services described the nature and scope of the services.

Based on review of medical records, policy review, and staff interview, it was determined the CAH failed to ensure nursing services met the needs of 6 of 31 patients (#2, #3, #7, #8, #10, and #11) whose records were reviewed. This resulted in the failure to appropriately monitor and care for patients, consistently document patient information in the record, and report abnormal findings to the physician. Findings include:

A CAH policy, "Documentation-Med/Surg," dated 1/01/90, stated "Accurate documentation reflects the quality of care and provides evidence of each health care team member's accountability in giving care. The purpose of the patient's record is to provide information for communication, education, assessment, research, financial billing, auditing, and legal documentation."

1. A CAH policy "Allergies," dated 1/20/17, stated "Each patient will receive a red wrist band upon admission. If the patient does have allergies, they will be listed on this band."Patient #3 was a 50 year old female who was seen in the ED on 1/04/17, with a diagnosis of suicidal ideations. She was transferred to another acute care facility on 1/04/17.

a. Patient #3's medical record included a nursing assessment, dated 1/04/17. The assessment documented "Allergy band placed on patient: No." However, it was documented that Patient #3 was allergic to Zetia, Penicillins, Buspirone, Chantix, and Morphine.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #3's medical record was reviewed in her presence. She confirmed Patient #3's allergies and stated a red wrist allergy band should have been placed.

The CAH failed to follow their policy and ensure Patient #3's allergies were identified.

b. Patient #7 was a 58 year old female admitted on 10/07/16, for left hip surgery.

Patient #7's record included an "Admissions Boarding Slip," dated 10/07/16, which documented she was allergic to sulfa and NSAID medications. An H&P documented Patient #7 was allergic to sulfa, Bactrim, and to avoid NSAID medications due to the likelihood of bleeding.

The nursing assessment, dated 10/07/16, did not include documentation of Patient #7's allergies, or that an allergy band was placed on her wrist.

Patient #7, on 10/10/16, had a surgical procedure on her left hip. The surgeon documented on her "Pre-Operative History and Physical," undated, Patient #7 was allergic to sulfa, Tramadol, and NSAID medications. However, Patient #7's "PREANESTHESIA EVALUATION," documented she was allergic to sulfa, aspirin, NSAIDs, and lorazepam.

During an interview at 8:35 AM on 2/10/17, the CNO reviewed the record and confirmed Patient #7's allergies were not consistent in her record.

Patient #7's record was inconsistent with documenting identification of her medication allergies. Patient #11 was a 15 year old female who was admitted for observation on 7/06/16, due to an overdose of medication and suicide attempt. She was discharged on 7/08/16.

2. Patient #11's record included physician's admission orders, dated 7/06/16 at 10:45 PM, for suicide precautions.

Her record included a document "SUICIDE WATCH," dated 7/07/16, which stated "DOCUMENT OBSERVATIONS OF PATIENT EVERY FIFTEEN (15) MINUTES." Documentation began every 15 minutes on 7/07/16, at 6:00 AM and continued until 7/08/16 at 9:15 AM when Patient #11 was discharged.

There was no documentation of observations for over 7 hours, between the time of the order on 7/06/16, at 10:45 PM and 7/07/16, at 6:00 AM.

The CNO and Compliance Officer were interviewed together on 2/9/17, at 10:53 AM. They reviewed Patient #11's record and confirmed documentation was missing that 15 minute checks had been conducted for over 7 hours. The CNO stated patients are usually put on 1:1 observation when suicide precautions are ordered. She confirmed there were not specific written guidelines for suicide precautions. She stated "it is assumed we watch them closely."

The CAH failed to meet the monitoring/safety needs of Patient #11, a suicidal adolescent.

3. Patient #10 was a newborn who was admitted to the hospital on 10/07/16, for hypothermia and discharged on 10/09/16. There was no documentation in the record vital signs were monitored between 10/08/16, at 5:30 PM and 10/09/16, at 5:12 AM; greater than 9 hours.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 10:45 AM. The CNO reviewed Patient #10's record and confirmed late or missing vital signs. She stated vital signs should have been monitored every 4 hours.

The CAH failed to meet Patient #10's needs for monitoring of vital signs.


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4. Patient #2 was a 49 year old female who was admitted on 2/02/17, with a diagnosis of SOB, hypoxia, ARF, hyponatremia (low serum sodium), and elevated liver enzymes.

Patient #2's medical record included a nurse's note, dated 2/03/17, and signed by the RN. The note stated "removed [sic] tubing from pump and free flowing PRBC into Pt. [sic] at 100 mL/hr." Additionally, the RN documented several times how the IV pump was not working. The note did not document if the RN attempted to use a different IV pump.

A CAH policy "Blood Administration," revised 11/14/13, was reviewed. The policy stated "Use IV Infusion Pump."

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #2's medical record was reviewed in her presence. She confirmed Patient #2 should have received blood administration via an IV pump per policy. The Compliance Officer stated the RN should have tried to use a different IV pump.

The CAH failed to follow their policy and ensure safe blood administration.

5. Patient #8 was a 14 year old male who was admitted on 12/02/16, with a diagnosis of DKA without coma.

A CAH policy "Critical Values," dated 10/08/09, stated "Notification of all critical values will be called to the physician..." The policy specified blood glucose levels < 50 mg/dl or > 400 mg/dl were to be reported.

Patient #8's medical record included a nursing flow sheet summary, undated. The flow sheet documented Patient #8's blood glucose of 44 mg/dl on 12/03/16, at 1:20 AM and 43 mg/dl on 12/03/16, at 6:20 AM. There was no documentation that Patient #8's RN contacted his physician regarding the critical blood glucose results.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #8's medical record was reviewed in her presence. She confirmed the RN did not document Patient #8's physician was notified of the critical blood glucose results.

The CAH failed to follow their policy and ensure Patient #8's physician was made aware of critical laboratory results.

Based on medical record review, CAH policy review, and staff interview, it was determined the CAH failed to ensure a nursing care plan was developed and kept current for 4 of 16 inpatients (#10, #23, #25, and #28) whose records were reviewed. This had the potential to result in uncoordinated nursing care that did not meet the needs of patients. Findings include:

A CAH policy "Care Plans," dated 7/22/11, stated "All patients at CMH will have a plan of care initiated on admission. Care plans provide direction for individualized care of the client. A care plan flows from each patient's unique list of diagnoses and should be organized by the individual's specific needs." The CAH failed to follow their policy.

1. Patient #10 was a newborn who was admitted to the hospital on 10/08/16, for hypothermia and discharged on 10/09/16.

A CAH policy "Acute Care Vital Signs," dated 8/14/12, stated "If vital signs are routine, they are done every four hours."

Patient #10's nursing care plan, "Hypothermia," included planned interventions to assess Patient #10's temperature every 4 hours and PRN. There was no documentation a temperature was taken between 10/08/16, at 5:30 PM and 10/09/16, at 5:12 AM; greater than 9 hours.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 10:45 AM. The CNO reviewed Patient #10's record and stated vital signs should have been monitored every 4 hours.

Patient #10's nursing care plan was not followed.

2. Patient #23 was a 94 year old female admitted on 8/01/16, for surgery and discharged to a SNF on 8/04/16.

Physician orders, progress notes, and nursing notes documented Patient #23 had oxygen, a surgical wound, a foley catheter, and required a hoyer lift. These items were not addressed on her nursing care plan.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 11:18 AM. The CNO reviewed Patient #23's record and confirmed the referenced items were not included on her nursing care plan.

Patient #23's nursing care plan was did not address her specified needs.

3. Patient #25 was a 21 year old female who was admitted on 12/29/16, with a diagnosis of fever of unspecified origin.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #25's medical record was reviewed in her presence. She confirmed Patient #25's medical record did not include a documented nursing care plan.

Patient #25's medical record did not include documentation of a nursing care plan.

4. Patient #28 was a 49 year old female who was admitted on 1/03/17, with a diagnosis of chest pain.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #28's medical record was reviewed in her presence. She confirmed Patient #28's medical record did not include a documented nursing care plan.

Patient #28's medical record did not include documentation of a nursing care plan.



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Based on review of medical records, staff interview, review of medical staff rules and regulations, and CAH policy review, it was determined the CAH failed to ensure a system was established for compiling and retrieving data for quality assurance activities. This resulted in incomplete records and physician authentication for 9 of 31 patients (#6, #8, #9, #12, #14, #19, #23, #25, and #29) whose records were reviewed and had the potential to interfere with quality improvement activities. Findings include:

The "MEDICAL STAFF RULES AND REGULATIONS," dated 6/28/16, was reviewed. It included the following information:

- "The patient's record should be complete within 30 days of discharge...

- A practitioner's routine orders when applicable to a given patient, shall be reproduced in detail in the patient's record, dated and signed (written/electronic) by the practitioner.

- If the record still remains incomplete 31 days after discharge of the patient, the Medical Record Director shall notify the practitioner that his admitting and operating room privileges shall be suspended within 72 hours from the date of the notice until his records are all complete."

Medical record policies were requested for review. The policies provided did not address a system for compiling and retrieving data for quality assurance activities.

The HIM Manager was interviewed on 2/08/17, at 9:15 AM. When asked to see any audit tools used to review records, she stated they did not use any audit tools; staff "just know" what to look for. She stated the transcriptionists looked at the records for any incompleteness by physicians or midlevel providers, and kept binders of information to inform the physicians and midlevel providers of medical record documentation that needed to be completed. She stated she let the CEO know when providers were more than 30 days late with chart delinquencies. She stated she believed the CEO talked to the physician' and midlevel providers. She stated she was not responsible for enforcement of medical staff rules.

Two transcriptionists were interviewed together on 2/08/17, at 9:45 AM. They stated they looked through records for items that related to physicians and midlevel practitioners (Nurse Practitioner, Physcician Assistant), for example H&P, ED dictation, signatures. They stated they did not work off any formalized checklists. Additionally, they stated if they saw something was missing, they kept folders or binders to alert physicians and midlevels of the deficiencies.

Physician documentation was not completed and signed within 30 days. These completions were not identified or reported for QAPI purposes. Examples include:

1. Patient #6 was 2 year old female who was admitted to the CAH on 11/08/16, and discharged on 11/10/16. The "HISTORY AND PHYSICAL," dated 11/08/16, was electronically signed by the physician on 2/03/17, 85 days after discharge.

2. Patient #9 was a 7 month old female who was admitted to the hospital on 8/24/16, with respiratory distress and discharged on 8/25/16. The "HISTORY AND PHYSICAL," dated 8/24/16, was electronically signed by the physician on 10/18/16, 55 days after discharge.

3. Patient #19 was an 87 year old female admitted to the CAH on 11/25/16, related to a UTI and discharged on 11/28/16. The "HISTORY AND PHYSICAL," dated 11/25/16, for Patient #19 was electronically signed by the physician on 2/03/17, 70 days after discharge.

4. Patient #23 was a 94 year old female admitted to the CAH on 8/01/16, for surgery and discharged to a SNF on 8/04/16. The "HISTORY AND PHYSICAL," dated 8/01/16, and the "OPERATIVE REPORT," dated 8/01/16, for Patient #23 were electronically signed by the physician on 10/03/16, 63 days after discharge.

5. Patient #25 was a 21 year old female who was admitted on 12/29/16, with a diagnosis of fever of unknown origin. The "HISTORY AND PHYSICAL," dated 12/29/16, was electronically signed by the physician on 2/03/17, 34 days after discharge.

6. Patient #29 was a 31 year old female who was admitted on 9/11/16, with a diagnosis of anaphylaxis. The "HISTORY AND PHYSICAL," dated 9/13/16, was electronically signed by the physician on 10/18/16, 35 days after discharge.

7. Patient #8 was a 14 year old male who was admitted on 12/02/16, with a diagnosis of DKA without coma. The "HISTORY AND PHYSICAL," dated 12/02/16, was electronically signed by the physician on 2/03/17, 63 days after discharge.

8. Patient #14 was a 1 day old, premature female, at 33 weeks gestation following a precipitous birth. The "CRITICAL CARE NOTE," dated 12/02/16, was electronically signed by the physician on 2/03/17, 63 days after discharge.

9. Patient #12 was an 8 year old female who was seen in the ED on 8/02/16, with a diagnosis of accidental poisoning. The "EMERGENCY DEPARTMENT REPORT," dated 8/02/16, was electronically signed by the physician on 10/18/16, 77 days after discharge.

The Compliance Officer was interviewed on 2/08/17, at approximately 11:00 am. She stated there was not a formal QA process for the Medical Records Department. She stated late signage of physician documentation was not identified or reported as a part of a QA process. She stated it should be reported but currently the hospital only kept track of and reports that were not dictated within 30 days.

The CAH failures to ensure a system was established for compiling and retrieving data for quality assurance activities.

Based on medical record review, staff rule and regulation review, CAH policy review, and staff interview, it was determined the CAH failed to ensure 19 of 31 medical records (#1, #2, #3, #5, #6, #8, #9, #12, #14, #15, #16, #17, #18, #25, #26, #27, #28, #29, and #30) included complete and accurate medical record entries. This had the potential to interfere with the coordination and provision of patient care. Findings include:

The "MEDICAL STAFF RULES AND REGULATIONS," dated 6/28/16, were reviewed. They included the following information:

- "A discharge summary shall be documented on all medical records of patients hospitalized over 24 hours except for normal obstetrical deliveries, normal newborn infants and certain selected patients with problems of a minor nature. These latter exceptions shall be identified by the medical staff, and for these a final summation - type progress note shall be sufficient.

- A practitioner's routine orders when applicable to a given patient, shall be reproduced in detail in the patient's record, dated and signed (written/electronic) by the practitioner.

- The patient's record should be complete within 30 days of discharge, including progress notes, final diagnosis and dictated discharge summary."

A CAH policy, "Documentation - Med/Surg," dated 1/01/90, was reviewed. It included the following information:

- "Chart only the care you provide or supervise.

- Fill in all blanks correctly. If you do not have information to fill in a blank, document with N/A.

- Chart accurately."

Medical record entries were either inaccurate or incomplete. Examples include:

1. Patient #1 was a 95 year old female who was admitted on 1/25/17, with a diagnosis of acute bronchitis.

a. Patient #1's medical record included a "PATIENT CARE INSTRUCTIONS," signed by the patient and the RN. Next to the her signature was a space for the time and date she received her discharge instructions. This space was blank.

b. Patient #1's medical record included an ED "Medical Consent Form," dated 1/25/17, and signed by the patient. At the bottom of the form was a space for the patient or patient representative to initial they received a copy of the CAH's notice of privacy practices. This space was left blank.

c. Patient #1's medical record included a "Swing Bed Admission Checklist," dated 1/25/17, and signed by the RN. The checklist included 33 lines. On each line was either a task or a medical record form to complete followed by a space for an RN's signature and date to indicate the task was completed. The following line items did not have an RN signature or date:

- "POST"

- "Skin Assessment within 2 hours of admit w/Braden Score"

- "Admission Assessment (must be an RN)"

- "Care Plan"

- "TB Test"

- "PASRR"

- "72 Hour Notice Given Before Discharge"

- "Behavior Monitoring Triggers in Care Plan if Indicated"

- "Restorative Assessment"

- "IDT's Weekly"

- "Home Health Referral Sheet"

- "Height/Weight on Admit Daily x 7 Days Then Weekly"

d. Patient #1's medical record included an "Admissions Boarding Slip," dated 1/24/17, and initialed by the physician. The form included a section titled "Plans for Post Discharge." This section was blank.

e. Patient #1's medical record included an "Inventory of Personal Effects," signed by a CNA. The form was not signed by Patient #1 or dated.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #1's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #1's record was incomplete.

2. Patient #28 was a 49 year old female who was admitted on 1/03/17, with a diagnosis of chest pain.

a. Patient #28's medical record included an ED "Medical Consent Form," dated 1/03/16 [sic], and signed by her husband. At the bottom of the form was a space for the patient or patient representative to initial they received a copy of the CAH's notice of privacy practices. This space was left blank. Additionally, the date of the form was documented as 2016 instead of 2017.

b. Patient #28's medical record included a "CHEST PAIN/ACS/UNSTABLE ANGINA/AMI PATHWAY," undated, and unsigned. The form served as a standing protocol/order and listed several interventions under the "TRIAGE CHEST PAIN PATIENTS." Next to each intervention was a space for the time the intervention was completed and the initials of the RN who completed the task. Additionally, there was a space next to each intervention for physician initials.

The form did not include physician initials next to each completed RN intervention. The form did not include a time or date next to the space for physician initials to indicate when the intervention was ordered. The form did not include a date next to the time the RN completed the ordered interventions. Additionally, the form did not include a signature legend for the purposes of identifying the RN or physician initials used.

c. Patient #28's medical record included an "Admissions Boarding Slip," dated 1/03/17, and initialed by the physician. The form included a section titled "Plans for Post Discharge." This section was blank.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #28's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #28's record was incomplete.

3. Patient #29 was a 31 year old female who was seen in the ED on 9/11/16, with a diagnosis of anaphylaxis.

a. Patient #29's medical record included an ED "Medical Consent Form," dated 9/11/16, and signed by the patient. At the bottom of the form was a space for the patient or patient representative to initial they received a copy of the CAH's notice of privacy practices. This space was left blank.

b. Patient #29's medical record included an inpatient "Medical Consent Form," signed by the patient. At the bottom of the form was a space for the patient or patient representative to initial they received a copy of the CAH's notice of privacy practices. This space was left blank. The consent was not dated.

c. Patient #29's medical record included an "Admissions Boarding Slip," initialed by the physician. The form was not dated. Additionally, the form included a section titled "Plans for Post Discharge." This section was blank.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #29's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #29's record was incomplete.

4. Patient #25 was a 21 year old female who was admitted on 12/29/16, with a diagnosis of fever of unspecified origin.

a. Patient #25's medical record included an inpatient "Medical Consent Form," signed by the patient. The consent was not dated.

b. Patient #25's medical record included a "CONSENT TO PHOTOGRAPH," signed by the patient. The consent did not include the date Patient #25 signed.

c. Patient #25's medical record included a "CONSENT TO PROCEDURE COLONOSCOPY/ESOPHAGOGASTRODUODENOSCOPY," signed by Patient #25 and the RN. A patient demographics section at the top of the form documented a date of 12/30/16. The RN signature at the bottom of the form documented a date of 12/30/16. However, there was no date documented as to when Patient #25 signed the consent.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #25's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #25's record was incomplete.

5. Patient #17 was a 53 year old female who was admitted to the ED on 1/02/17, and died on 1/03/17.

a. Patient # 17's "MEDICAL CONSENT FORM" was signed by an individual other than the patient. The date of signature, and the relationship to Patient #17, was not included on the form. The information was left blank.

b. The form "Organ and Tissue Notification," included the time Patient #17's death was reported to the organ procurement organization. However, it did not include the date of notification.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 11:09 AM. They confirmed the missing date, relationship to Patient #17 on the consent form, and the missing date on the form to notify the organ procurement organization.

Patient #17's record was incomplete.

6. Patient #14 was a 1 day old, premature female, at 33 weeks gestation following a precipitous birth on 12/02/16.

a. Patient #14's medical record included an ED "Medical Consent Form," signed by the patient's father. At the bottom of the form was a space for the patient or patient representative to initial they received a copy of the CAH's notice of privacy practices. This space was left blank.

b. Patient #14's medical record included an "EMTALA Transfer Request Form," dated 12/02/16, and initialed by the physician. The form did not document the following information:

- If the receiving hospital physician had received a physician-to-physician report.

- If an RN or physician would accompany Patient #14 during her transfer.

- How Patient #14 was receiving supplemental oxygen.

- What IV fluids were running through Patient #14's umbilical IV access.

- Who signed the consent to transfer Patient #14.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #14's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #14's record was incomplete.

7. Patient #27 was a 73 year old male who was admitted on 9/21/16, with a diagnosis of right hip pain.

a. Patient #27's medical record included a swing bed "Medical Consent Form," signed by the patient. The date of the consent was illegible.

b. Patient #27's medical record included an "Admissions Boarding Slip," dated 9/21/16, and initialed by the physician. The form included a section titled "Plans for Post Discharge." This section was blank.

Patient #27's record was incomplete.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #27's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

8. Patient #3 was a 50 year old female who was seen in the ED on 1/04/17, with a diagnosis of suicidal ideations.

a. Patient #3's medical record included an ED "Medical Consent Form," signed by the patient. At the bottom of the form was a space for the patient or patient representative to initial they received a copy of the CAH's notice of privacy practices. This space was left blank. Additionally, the consent was not dated.

b. Patient #3's medical record included an "EMTALA Transfer Request Form," dated 1/04/17, and signed by the physician. The form did not document her transfer time or discharge vital signs.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #3's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #3's record was incomplete.

9. Patient #15 was a 91 year old male with a DNR order who arrived at the ED on 11/21/16.

The ED record, dated 11/21/17, documented Patient #15 arrived without vital signs and did not revive during the ED visit. He was pronounced dead. The section of the ED records, identified as "Allergies" included the following information: "Sulfa (Sulfonamide Antibiotics) Group Unknown with : PT CANT REMEMBER. HE HAD SOME TYPE OF REACTION 50 YEARS AGO." It could not be determined how Patient #15 provided this information if he was dead on arrival.

The CNO was interviewed on 2/09/17, at 10:15 AM. She confirmed the information was not obtained during the ED visit. She stated the EMR information carried forward from a prior visit on 5/12/16, after nursing staff prompted the software to verify the allergies. She confirmed the information could not have been verified based on Patient #15's status.

Patient #15's record was incomplete.

10. Patient #6 was 2 year old female who was admitted to the CAH on 11/08/16, and discharged on 11/10/16. Patient #6's "MEDICAL CONSENT FORM" was signed. The relationship to Patient #6 was not documented. The information was left blank.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 10:26 AM. They confirmed the relationship to Patient #6 was not stated.

Patient #6's record was incomplete.

11. Patient #9 was a 7 month old female admitted to the CAH on 8/24/16, with respiratory distress and discharged on 8/25/16. Patient #9's "MEDICAL CONSENT FORM" was signed. The relationship to Patient #9 was not documented.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 10:40 AM. They confirmed the relationship to Patient #9 was not stated.

Patient #9's record was incomplete.

12. Patient #30 was a 74 year old male admitted to the CAH on 12/21/16, for dyspnea. He died on 12/23/16.

The form "Organ and Tissue Notification," included documentation of the time Patient #30's death was reported to the Organ Procurement Organization. It, however, did not include the date of notification.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 11:28 AM. They confirmed the missing date on the organ procurement form.

Patient #30's record was incomplete.

13. Patient #2 was a 49 year old female who was admitted on 2/02/17, with a diagnosis of SOB, hypoxia, ARF, hyponatremia (low serum sodium), and elevated liver enzymes.

Patient #2's medical record included an "Admissions Boarding Slip," initialed by the physician. The form was not dated. Additionally, the form included a section titled "Admit To." This section was blank.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #2's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #2's record was incomplete.

14. Patient #8 was a 14 year old male who was admitted on 12/02/16, with a diagnosis of DKA without coma.

Patient #8's medical record included an "Admissions Boarding Slip," initialed by the physician. The form was not dated or timed. Additionally, the form included a section titled "Plans for Post Discharge." This section was blank.

The Compliance Officer was interviewed on 2/09/16, beginning at 2:15 PM, and Patient #8's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #8's record was incomplete.

15. Patient #18 was a 13 year old female who was seen in the ED on 1/20/17, with a diagnosis of suicide attempt.

Patient #18's medical record included an "Admissions Boarding Slip," dated 1/20/17. The form included a section titled "Plans for Post Discharge." This section was blank. The form was not signed by the physician.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #18's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #18's record was incomplete.

16. Patient #12 was an 8 year old female who was seen in the ED on 8/02/16, with a diagnosis of accidental poisoning.

Patient #12's medical record included an ED "Medical Consent Form," dated 8/02/16, and signed by the patient's mother. At the bottom of the form was a space for the patient or patient representative to initial they received a copy of the CAH's notice of privacy practices. This space was left blank.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #12's medical record was reviewed in her presence. She confirmed the clinical documention was incomplete.

Patient #12's record was incomplete.

17. Patient #5 was a 36 year old male brought to the ED on 11/08/16 for chest pain.

Patient #5's record included an EMTALA transfer request form. The form did not include documentation of the date and time the receiving facility and physician accepted the transfer of Patient #5.

During an interview at 8:47 AM on 2/10/17, the CNO reviewed the record and confirmed the EMTALA form was incomplete.

Patient #5's record was incomplete.

18. Patient #16 was a 33 week old, premature male, delivered in the ED on 12/02/16.

Patient #16's medical record included an EMTALA transfer request form, dated 12/02/16, initialed by the physician. The form did not include documentation of report to the receiving physician. Additionally, there was no documentation of what IV fluid was running during transport, the rate, or that Patient #16 was intubated and on a ventilator.

During an interview at 8:20 AM on 2/10/17, the CNO reviewed the record and confirmed the EMTALA form was incomplete.

Patient #16's record was incomplete.

19. Patient #26 was an 81 year old female admitted on 9/02/16, for inflammation of her cecum (a pouch connected to the small and large intestines).

Patient #26's record included an order, dated 9/05/16, for a blood transfusion of 2 units of packed red blood cells. The "Blood Component Administration Record" documented the first unit of blood started at 3:59 PM on 9/05/16. The "Consent for Blood Transfusion" form was signed and dated by Patient #26, but there was no documented time when she signed the consent.

During an interview at 8:30 AM on 2/10/17, the CNO reviewed the record and confirmed the consent for the blood transfusion did not include a time.

The CAH failed to ensure the blood transfusion consent was completed prior to Patient #26's transfusion.



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Based on review of CAH policy, review of medical records, and staff interview, it was determined the CAH failed to ensure properly executed consent was obtained for 1 of 1 adolescent patient presenting to the ED (#11) whose record was reviewed. This resulted in a suicidal minor giving her own consent to treat. Findings include:

A CAH policy "Consent Policy for Treatment in the ED," dated 5/2015, included the following information:

"In the event of a minor (under age 18) presenting to the ED without a parent or guardian for treatment, the following are acceptable means of obtaining consent:

1. Parent(s) or guardians will be contacted by phone for permission to treat.

2. Telephone consents shall be witnessed by two (2) persons and shall be documented on the consent form.

3. Another adult blood relative may be contacted for consent if unable to contact the parents. This may be a grandparent, adult sibling, aunt, or uncle.

4. Designated guardian of the minor may give consent.

5. The patient will be considered emancipated if the patient is married; merely having a child while unwed does not imply emancipation.

6. However, the unwed minor mother of a child has the right to give permission for her child to be treated.

7. A patient is considered emancipated when he/she is living separate and apart from his/her parents of legal guardian and is managing his/her own financial affairs.

8. A minor greater than age 14 years does not require parental permission for psychiatric evaluation or treatment. If treatment is initiated without written consent, the circumstances surrounding the event and the steps taken to obtain consent will be documented in the ED record."

A CAH policy, "General Consent," dated 11/12/15, was reviewed. It stated "If the patient is unable to sign the general consent for care at the time of admission and his/her legal representative is not available, the consent shall be flagged and placed in the patient record. Reasonable efforts shall be made to obtain a signature at a later time during the admission."

Patient #11 was a 15 year old female who was admitted for observation on 7/06/16, due to an overdose of medication and suicide attempt. She was discharged on 7/08/16.

The consent form was signed by Patient #15 who was a minor. There were no documented attempts to have parents authorize consent.

The CNO and Compliance Officer were interviewed together on 2/9/17 at 10:53 AM. They confirmed the consent was signed by Patient #11 rather than a responsible adult as required by hospital policy.

Consent was not properly executed for Patient #11.


37262

Based on review of medical records, review of medical staff rules and regulations, and staff interview, it was determined the CAH failed to ensure medical record entries were dated, timed, and signed by the MD/DO for 20 of 31 patients (#2, #6, #7, #8, #9, #10, #11, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30) whose records were reviewed . This resulted in a lack of clarity regarding authentication of medical record entries. Findings include:

The "MEDICAL STAFF RULES AND REGULATIONS," dated 6/28/16, were reviewed. They included the following information:

- "A practitioner's routine orders when applicable to a given patient, shall be reproduced in detail in the patient's record, dated and signed (written/electronic) by the practitioner."

The medical staff rules and regulations did not address the appropriate way for medical staff to correct an error in a handwritten note.

1. Patient #27 was a 73 year old male who was admitted on 9/21/16, with a diagnosis of right hip pain.

a. The "Admissions Boarding Slip" was initialed by the physician, but was not dated or timed.

b. A telephone order was dated 9/22/16, by the RN, and initialed by the physician. The order was not timed by the physician.

c. There were 3 telephone orders dated 9/23/16, by the RN, and initialed by the physician. The 3 orders were not dated or timed by the physician.

d. An order was dated 9/23/16, by the physician, and initialed. The order was not timed.

e. There were telephone orders dated 9/24/16, 9/26/16, and 9/28/16, by the RN, and initialed by the physician. The orders were not dated or timed by the physician.

f. There were orders dated 9/28/16, 10/01/16, 10/02/16, and 10/03/16, by the physician, and initialed. The orders were not timed.

g. Telephone orders were dated 10/03/16, 10/04/16, 10/05/16, 10/07/16, 10/09/16, and 10/14/16, by the RN, and initialed by the physician. The orders were not dated or timed by the physician.

h. An order was dated 10/13/16, by the physician, and initialed. The order was not timed.

i. Physician progress notes were dated 9/22/16, 9/23/16, 9/24/16, 9/25/16, 9/30/16, 10/02/16, and 10/03/16, by the physician, and initialed. The notes were not timed.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #27's medical record was reviewed in her presence. She confirmed the order authentications were incomplete.

The physician's did not date, time, or sign all of their entries in Patient #27's medical record.

2. Patient #26 was an 81 year old female admitted on 9/02/16, for inflammation of her cecum (a pouch connected to the small and large intestines). Her record included physician orders and progress notes which were incomplete.

a. Physician orders dated 9/03/16, were signed but not timed by the physician.

b. Verbal orders dated 9/03/16, by the RN, were signed by the physician but not dated or timed.

c. Physician orders and progress notes dated 9/04/16, were dated and initialed by the physician but were not timed.

d. Physician orders dated 9/04/16, were signed by the physician but not timed.

e. Physician orders and progress notes dated 9/05/16, 9/06/16, and 9/07/16, were dated and initialed by the physician but not timed.

f. A telephone order, dated 9/07/16, and signed by the RN, was not signed by the physician.

g. Discharge orders, dated 9/08/16, were signed by the physician but not timed.

During an interview at 8:30 AM on 2/10/17, the CNO reviewed the record and confirmed there were missing dates, times, and signatures for physician orders and progress notes.

The physician did not date, time, or sign all of his entries in Patient #26's medical record.

3. Patient #24 was a 52 year old female admitted on 10/22/16, for pancreatitis. Her record included physician orders and progress notes which were incomplete.

a. Patient #24's record included an Admissions form, dated 10/23/16, and signed by the physician. However, the physician's signature was not timed.

b. Physician progress notes and orders, dated 10/23/16, were initialed by the admitting physician however there was no time.

c. Physician progress notes, dated 10/24/16, were not timed or signed by the admitting physician.

d. Physician orders, dated 10/24/16, were initialed by the physician but not timed.

e. Verbal and telephone orders documented by the RN on 10/24/16, were initialed by the admitting physician. However, he did not date or time his initials.

f. Discharge orders, dated 10/25/16, were initialed by the admitting physician but were not timed.

During an interview at 8:15 AM on 2/10/17, the CNO reviewed the record and confirmed there was missing times and signatures for orders and progress notes.

The physician's did not date, time, or sign all of their entries in Patient #24's medical record.

4. Patient #7 was a 58 year old female admitted on 10/07/16, for left hip surgery. Her record included physician orders which were incomplete.

a. Patient #7's record included an Admissions form, dated 10/07/16, which was initialed by the physician but was not timed.

b. Physician progress notes dated 10/08/16, 10/09/16, 10/12/16, and 10/13/16, were not timed by the physician.

c. Physician orders signed by the RN on 10/08/16, were initialed by the physician but did not include a date or time.

d. Physician orders dated 10/09/16, 10/12/16, and 10/13/16, were initialed by the physician but did not include a time.

During an interview at 8:35 AM on 2/10/17, the CNO reviewed the record and confirmed there were missing dates, times, and signatures for physician orders and progress notes.

The physician did not date, time, or sign all of his entries in Patient #7's medical record.

5. Patient #29 was a 31 year old female who was admitted on 9/11/16, with a diagnosis of anaphylaxis.

a. The "Admissions Boarding Slip" was dated 9/11/16, and initialed by the physician. The order was not timed by the physician.

b. A telephone order was dated 9/12/16, by the RN, and initialed by the physician. The order was not dated or timed by the physician.

c. A discharge order was initialed by the physician. The order was not dated or timed by the physician.

d. A progress note was dated 9/12/16, by the physician, and initialed. The progress note was not timed by the physician.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #29's medical record was reviewed in her presence. She confirmed the order authentications were incomplete.

The physician's did not date, time, or sign all of their entries in Patient #29's medical record.

6. Patient #8 was a 14 year old male who was admitted on 12/02/16, with a diagnosis of DKA without coma.

a. The "Admissions Boarding Slip" was dated 12/02/16, by the physician, and initialed. The order was not timed by the physician.

b. There were 4 telephone orders dated 12/02/16, by the RN. The 4 orders were not signed, dated, or timed by the physician.

c. A progress note was dated 12/03/17, by the physician, and initialed. The progress note was not timed by the physician.

d. A discharge order was initialed by the physician. The order was not dated or timed by the physician.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #8's medical record was reviewed in her presence. She confirmed the order authentications were incomplete.

The physician's did not date, time, or sign all of their entries in Patient #8's medical record.

7. Patient #21 was a 46 year old female who was admitted on 8/18/16, for respiratory failure and transferred on 8/19/16.

a. Physician orders, dated 8/18/16 and 8/19/16, were initialed. The orders were not timed.

b. Physician progress notes, dated 8/19/16, were initialed. The orders were not timed.

c. The "EMTALA Transfer Request Form," dated 8/19/16, was initialed by the physician. The form was not timed.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 11:30 AM. They confirmed the physician's orders, progress note, and EMTALA forms were not timed.

The physician's did not date, time, or sign all of their entries in Patient #21's medical record.

8. Patient #20 was a 72 year old male who was admitted to the CAH for evaluation of chest pain on 9/13/16, and discharged on 9/15/16.

a. Physician admission orders, dated 9/13/16, were not signed or timed.

b. Physician orders and progress notes, dated 9/15/16, were not timed.

c. Nursing notes, dated 9/14/16, from 8:00 AM - 6:00 PM, were written in the form of a block of time. It could not be determined the timing of the course of care.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 11:37 AM. They confirmed the physician's orders and progress notes were missing dates of times. The CNO confirmed the block charting and stated that block charting was not allowed.

The physician's did not date, time, or sign all of their entries in Patient #20's medical record.

9. Patient #25 was a 21 year old female who was admitted on 12/29/16, with a diagnosis of fever of unknown origin.

a. The admission orders were initialed by the physician. The orders were not dated or timed.

b. Telephone orders were dated 12/29/16, 12/30/16, and 12/31/16, by the RN, and initialed by the physician. The orders were not dated or timed by the physician.

c. There are 2 physician progress notes which are initialed by the physician, but not dated or timed.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #25's medical record was reviewed in her presence. She confirmed the order authentications were incomplete.

The physician's did not date, time, or sign all of their entries in Patient #25's medical record.

10. Patient #6 was 2 year old female who was admitted to the CAH on 11/08/16 and discharged on 11/10/16.

a. The admission orders, dated 11/08/16, were initialed by the physician. The orders were not timed.

b. The physician progress notes, dated 11/09/16 and 11/10/16, were initialed by the physician. The progress notes were not timed.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 10:26 AM. They confirmed missing times on physician orders and progress notes.

The physician's did not date, time, or sign all of their entries in Patient #6's medical record.

11. Patient #9 was a 7 month old female who was admitted to the hospital on 8/24/16 with respiratory distress and discharged on 8/25/16.

a. The admission orders, dated 8/14/16, were initialed by the physician. The orders were not timed.

b. The physician progress notes, dated 8/24/16 and 8/25/16, were initialed by the physician. The progress notes were not timed.

The CNO and Compliance Officer were interviewed together on 2/09/17 at 10:40 AM. They confirmed missing times on physician orders and progress notes.

The physician's did not date, time, or sign all of their entries in Patient #9's medical record.

12. Patient #10 was a newborn who was admitted to the hospital on 10/08/16, for hypothermia and discharged on 10/09/16.

a. The physician's hand written "Initial Note," was initialed. It was not dated or timed.

b. The physician's orders and progress notes, dated 10/08/16 and 10/09/16, were initialed. The orders and progress notes were not timed.

The CNO and Compliance Officer were interviewed together on 2/09/17 at 10:45 AM. They confirmed the missing dates and times.

The physician's did not date, time, or sign all of their entries in Patient #10's medical record.

13. Patient #11 was a 15 year old female who was admitted for observation on 7/06/16, due to an overdose of medication and suicide attempt. She was discharged on 7/08/16.

a. The physician's orders for Patient #11, dated 7/07/16 and 7/08/17, were initialed by the physician. The orders were not timed.

b. Physician progress notes for Patient #11 were initialed. They were not dated.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 10:53 AM. They confirmed the missing dates and times.

The physician's did not date, time, or sign all of their entries in Patient #11's medical record.

14. Patient #30 was a 74 year old male was admitted on 12/21/16, related to dyspnea. He died on 12/23/16.

a. Physician admission orders for Patient #30, dated 12/21/16, were initialed by the physician. The orders were not timed.

b. Physician progress notes for Patient #30, dated 12/22/16, were initialed by the physician. The progress notes were not timed.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 11:28 AM. They confirmed the physician's orders and progress notes were not timed.

The physician's did not date, time, or sign all of their entries in Patient #30's medical record.

15. Patient #19 was an 87 year old female admitted to the CAH on 11/25/16, related to a UTI and discharged on 11/28/16.

The admission orders, dated 11/25/16 at 12:30 PM, for Patient #19 included crossed out orders, without corresponding initials or dates or note, such as "mistaken entry."

The CNO and Compliance Officer were interviewed together on 2/09/17 at 11:12 AM. They confirmed the crossed out orders without corresponding date or initials. When asked for physician documentation guidelines for how to correct an error, the CNO researched the information and stated there were not any physician guidelines, just nursing guidelines.

The physician's did not date, time, or sign all of their entries in Patient #19's medical record.

16. Patient #23 was a 94 year old female admitted to the CAH on 8/01/16, for surgery and discharged to a SNF on 8/04/16.

Physician's orders for Patient #23, dated 8/01/16, 8/02/16, and 8/03/16, were initialed by the physician. The orders were not timed.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 11:18 AM. They confirmed physician orders were not timed.

The physician's did not date, time, or sign all of their entries in Patient #23's medical record.

17. Patient #22 was an 81 year old female admitted to the CAH on 1/24/17, for chest pain and discharged on 1/25/17.

Physician's orders for Patient #22, dated 1/24/17, were initialed by the physician. The orders were not timed.

The CNO and Compliance Officer were interviewed together on 2/09/17, at 11:24 AM. They confirmed the physician's orders were not timed.

The physician's did not date, time, or sign all of their entries in Patient #22's medical record.

18. Patient #2 was a 49 year old female who was admitted on 2/02/17, with a diagnosis of SOB, hypoxia, ARF, hyponatremia (low serum sodium), and elevated liver enzymes.

The "Admissions Boarding Slip" was dated 2/02/17, by the physician, and initialed. The order was not timed by the physician.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #2's medical record was reviewed in her presence. She confirmed the order authentication was incomplete.

The physician's did not date, time, or sign all of their entries in Patient #2's medical record.

19. Patient #18 was a 13 year old female who was seen in the ED on 1/20/17, with a diagnosis of suicide attempt.

The "Admissions Boarding Slip" was not signed, dated, or timed by the physician.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #18's medical record was reviewed in her presence. She confirmed the order authentication was incomplete.

The physician's did not date, time, or sign all of their entries in Patient #18's medical record.

20. Patient #28 was a 49 year old female who was admitted on 1/03/17, with a diagnosis of chest pain.

There were 2 medication orders dated 1/04/17, by the RN, and signed by the physician. The orders were not dated or timed by the physician.

The Compliance Officer was interviewed on 2/09/17, beginning at 2:15 PM, and Patient #28's medical record was reviewed in her presence. She confirmed the order authentications were incomplete.

The physician's did not date, time, or sign all of their entries in Patient #28's medical record.


37262




34507

Based on review of CAH policies, review of QAPI documentation, and staff interview, it was determined the CAH failed to ensure CAH health care policies were evaluated once a year. This resulted in outdated policies and had the potential to interference with quality and safety of patient care. Findings include:

Refer to C-272 as it relates to the failure of the CAH to ensure annual review of health care policies.

Based on staff interview, CAH policy review, medical record review, and admission documentation review, it was determined the CAH failed to ensure visitation rights were provided to each patient or his/her representative for 31 of 31 patients (#'s 1-31) whose records were reviewed. This had the potential to interfere with the exercise of visitation rights. Findings include:

A CAH policy "Visitation Rights," dated 9/20/11, was reviewed. The policy included the following information:

- "The CAH will provide written notice of the patient visitation rights to each patient (or the patient's support person).

- The notice of visitation rights may be included in and shall be provided at the same time that notice of other patient rights is provided to the patient."

The Admission packet was reviewed. It did not include information on admission rights.

A CAH policy "Patient Admission," dated 10/01/2003, was reviewed. It included procedures for outpatient and admission admissions. The policy did not address the need to provide visitation rights as a part of the admission process.

Medical records for Patient #'s 1-31 were reviewed. They did not include documentation that visitation rights had been provided.

An Admissions Registration staff member was interviewed on 2/08/17, at 9:00 AM. She stated they did not routinely provide visitation rights, but did offer them to inpatients. She stated they did not offer them to outpatients and did not specifically document in the medical record when written notice of visitation rights had been provided.

The CAH failed to ensure visitation rights were provided to each patient or his/her representative.