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Based on staff interview and review of Idaho state statutes and licensing rules and review of the CAH's Governing Body bylaws, it was determined the CAH failed to ensure it maintained compliance with those statutes and licensing rules. This resulted in the CAH's inability to provide required services to meet the state definition of a hospital. Findings include:

1. Idaho state statutes 39-1301 defines a hospital as "a facility which:
(1) Is primarily engaged in providing, by or under the supervision of physicians,
(a) concentrated medical and nursing care on a twenty-four (24) hour basis to inpatients experiencing acute illness."

The CAH failed to maintain compliance with state hospital statutes.

The CNO was interviewed on 6/05/17 beginning at 11:30 AM. She stated the CAH had 1 physician who actively practiced at the hospital and who was the Medical Director. She stated the physician left that day on vacation and would be out of the country for 10 days. She also stated he was not available by phone. She stated the CAH did not have another physician to provide direct care or to provide oversight or supervision of medical care during those 10 days.

The CNO stated the CAH provided inpatient services. She stated because of the lack of physician services, the CAH would not admit any patients for inpatient services. She stated the hospital did not have a formal plan to address situations where a physician was not available to the hospital.

The CNO was also interviewed on 6/06/17 beginning at 8:10 AM. She stated, if the CAH had inpatients at a time when the physician became unavailable, those patients would be transferred to a facility that was able to care for inpatients. She stated she did not know what dates the CAH had ceased to provide inpatient services in the past because the CAH did not track times when inpatient services were not available.

The CAH failed to comply with state licensure requirements.

2. "RULES AND MINIMUM STANDARDS FOR HOSPITALS IN IDAHO," 16.03.14.200.01, are the licensing requirements hospitals must meet, The rules, reviewed on the state of Idaho web site on 6/09/17, stated Governing Body "...bylaws shall specify that every patient be under the care of a physician licensed by the Idaho State Board of Medicine." The rules state, "The bylaws shall specify that a physician be on duty or on call at all times." Finally, the rules also call for the bylaws to state "Patients being treated by nonphysician practitioners shall be under the general care of a physician."

In addition, Idaho state licensing rules do not allow for the intermittent stoppage of hospital services.

Cascade Medical Center "HOSPITAL BYLAWS OF THE BOARD OF TRUSTEES," revised 12/2012, stated Medical Staff bylaws would contain a "...provision requiring that all patients admitted to the hospital be under the care of a physician licensed by the Idaho State Board of Medicine and that all patients being treated by nonphysician practitioners be under the care of a physician so licensed." The bylaws did not state that a physician would be on duty or on call at all times.

The bylaws were incomplete and the CAH did not enforce the bylaws regarding the provision of physician services. A state licensure deficiency was cited on 6/12/17 related to the lack of physician services.

The CAH failed to maintain compliance with state licensing rules.

3. Refer to C151 as it relates to the failure of the CAH to comply with federal regulations related to advanced directives.

The failure to comply with state and federal requirements limited the CAH's ability to provide care and services.

Based on record review, policy review and staff interview, it was determined the facility failed to ensure compliance with Federal laws and regulations related to advanced directives for 1 of 2 inpatients (Patient #1) whose records were reviewed. This resulted in a lack of documentation in a patient's record that they were informed of their right to formulate advanced directives, such as a living will or durable power of attorney. Findings include:

An advanced directive is defined at 42 CFR 489.100 as "a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated." In accordance with the provisions of 42 CFR 489.102(a), the advanced directives regulations apply to CAHs. 42 CFR 489.102(b)(1) requires that notice of the CAH's advanced directives policy be provided at the time an individual is admitted as an inpatient.

A facility policy titled Patient Advance Directive Record, dated 10/19/16, stated "All patients over the age of 18 admitted to [hospital's name] will have information on advance directives included in their medical record." The policy also stated "If an advance directive is not available, the nurse should have the patient complete one."

1. Patient #1 was a 77 year old female who was admitted to acute care services on 5/30/17 for treatment of community acquired pneumonia and hypoxia.

Review of Patient #1's record showed no documentation related to advance directives.

In an interview on 6/07/17 at 2:00 P.M., the CNO said patient admission packets contained patient education pertaining to advance directives as well as a patient signature form acknowledging receipt of the education and indicating if they had current advance directives. A blank patient admission packet was reviewed and confirmed this information was presented.

However, when requested, a patient signature form could not be provided for Patient #1.

In the same interview, the CNO confirmed an advance directive signature form for Patient #1 was not present.

Advance directive information was not presented and status was not obtained for an inpatient.

Based on staff interview and policy review, it was determined the CAH failed to ensure a physician was available by telephone or radio contact to receive emergency calls and provide treatment information for emergency patients in coordination with emergency response systems. This resulted in a lack of physician support to emergency personnel. Findings include:

A policy was not available which specified a physician was available to emergency response systems in the area.

The CNO was interviewed on 6/07/17 beginning at 1:40 PM. She stated the CAH had not developed a policy regarding physician availability to emergency response systems. She stated the CAH did not currently have a physician available to communicate with emergency response systems.

The CAH failed to develop a system to communicate with emergency response systems.

Based on staff interview and review of Idaho state statutes and licensing rules and review of the CAH's Governing Body bylaws, it was determined the CAH's organizational structure was insufficient to ensure it maintained compliance with fundamental operating principles. This resulted in the CAH's inability to provide required services to meet the state definition of a hospital. Findings include:

Refer to C241 as it relates to the failure of the governing body to assume responsibility for maintaining compliance with state and federal requirements.

The governing body's failure to address basic operational needs limited the CAH's ability to provide care and services.

Based on staff interview and review of governing body meeting minutes, it was determined the CAH's governing body failed to assume responsibility to ensure it maintained compliance with state statutes and licensing rules. This resulted in a lack of planning and direction to CAH staff. Findings include:

1. The CAH had 1 physician and 4 mid-level practitioners who actively practiced at the hospital. Since the hospital only had 1 physician, it was reasonable to assume that physician would have times when he was not able to provide services to the CAH.

Four Board of Trustee meeting minutes were available between 1/01/17 and 6/05/17. None of the minutes addressed issue of physician availability.

The CNO was interviewed on 6/05/17 beginning at 11:30 AM. She stated the CAH had 1 physician who actively practiced at the hospital and who was the Medical Director. She stated the physician left that day on vacation and would be out of the country for 10 days. She also stated he was not available by phone. She stated the CAH did not have another physician to provide direct care or to provide oversight or supervision of medical care during those 10 days.

The CNO stated the CAH provided inpatient services. She stated because of the lack of physician services, the CAH would not admit any patients for inpatient services. She stated the hospital had not developed a plan to address situations where a physician was not available to the hospital.

The CNO was also interviewed on 6/06/17 beginning at 8:10 AM. She stated, if the CAH had inpatients at a time when the physician became unavailable, those patients would be transferred to a facility that was able to care for inpatients. She stated there was no plan to address this situation.

Board Member A was interviewed on 6/08/17 beginning at 8:55 AM. She stated she was not aware of a plan that outlined how the CAH would provide services if the physician was not available. She stated the Board of Trustees talked about the physician situation but she said they had not developed a plan to address interruptions in service.

The CAH's governing body failed to plan for the provision of necessary services during physician absences.

2. Refer to C150 as it relates to the governing body's failure to ensure the CAH maintained compliance with Idaho state statutes and licensing rules.

Based on staff interview and review of policies and infection control information, it was determined the CAH failed to ensure basic processes to prevent infections were developed. This resulted in an increased risk of infections to all CAH patients. Findings include:

A hand hygiene policy was not present at the CAH.

The Infection Control Officer was interviewed on 6/07/17 beginning at 12:50 PM. She stated the CAH had not developed a hand hygiene policy. She also stated no hand hygiene monitoring of staff was conducted since at least 6/01/16. Finally, she stated the CAH did not have a policy related to the treatment of patients with multi-drug resistant organisms.

The CAH failed to develop and monitor infection control policies.

Based on staff interview, it was determined the CAH failed to ensure the CEO assumed responsibility for services furnished in the CAH. This resulted in a lack of preparation when staff shortages occurred. Findings include:

The CNO was interviewed on 6/05/17 beginning at 11:30 AM. She stated the CAH had 1 physician who actively practiced at the hospital and who was the Medical Director. She stated the physician left that day and would be out of the country for 10 days. She also stated he was not available by phone. She stated the CAH did not have another physician to provide direct care or to provide oversight or supervision of medical care during those 10 days. The CNO also stated the hospital was currently unable to provide inpatient services due the lack of physician services.

The CNO stated because of the lack of physician services, the CAH would not admit any patients for inpatient care. She stated the hospital did not have a formal plan to address situations where a physician was not available to the hospital.

The CEO was interviewed on 6/07/17 beginning at 3:15 PM. He stated he knew the CAH's only physician was not going to be available for 10 days beginning the week of 6/05/17. He stated he had been trying to hire a long term physician. But he stated the CAH had not developed a plan to address short term physician shortages and how the CAH would provide physician services during those times. He also stated there was no plan to maintain inpatient services during physician shortages.

The CEO failed to ensure contingency plans were in place during times of physician shortages.

Based on staff interview and review of medical records and policies, it was determined the CAH failed to ensure an effective QA program was maintained, including a process to analyze adverse patient events and failures of processes. This affected the care of 2 of 2 patients (#14 and #19), who had unusual incidents during their care. This resulted in the inability of the CAH to review events that impacted patient care. Findings include:

1. The policy "INCIDENT REPORT," not dated, stated "An incident is an occurrence not consistent with the desired operation of this medical center, or the care of patients." The policy stated these reports would be reviewed "...for recommendation and corrective action." This policy was not followed.

Patient #19 was a 57 year old female who suffered cardiac arrest and was brought to the CAH for attempted resuscitation on 3/31/17 at 6:54 PM. CPR was initiated by nursing staff upon her arrival. She was pronounced dead on 3/31/17 at 7:13 PM.

Patient #19's medical record stated the practitioner, a PA, was notified of the patient's arrival on 3/31/17 at 6:55 PM and he arrived at the CAH at 7:13 PM.

The RN on duty when Patient #19 arrived was interviewed on 6/17/17 beginning at 8:50 AM. She stated Patient #19 arrived on 3/31/17 in full arrest. She stated the hospital had advance notice of Patient #19's condition around 5:00 PM. She stated the PA waited at the CAH for a while and then left. The RN stated, when Patient #19 arrived, the PA had to be notified by phone and then he returned to the CAH, which took approximately 18 minutes. The RN stated she did not complete an incident report but said she did notify the physician of events after the fact.

The CNO was interviewed on 6/08/17 beginning at 1:00 PM. She stated she was aware of the above event. She stated an incident report was not completed and an investigation of the event was not conducted. She also stated no incident reports had been completed in the year preceding the survey.

The CAH did not identify and investigate the PA's availability to Patient #19.

2. Patient #14 was an 80 year old female who presented to the emergency department on 5/13/17 at 6:00 AM. She was evaluated for chest pain. She was discharged home at 11:00 AM that same day. Patient #14 had a complete blood count drawn at 6:45 AM. The test showed her white blood cells were very low at 1.36 and her hemoglobin and hematocrit levels were also low. The blood was redrawn at 8:32 AM and run again. This time the tests were normal.

The Laboratory Manager was interviewed on 6/07/17 beginning at 10:20 AM. She stated she questioned the accuracy of Patient #14's original laboratory tests and had her blood redrawn. She stated the second tests were normal. She stated she did not know why the first tests were not accurate. She stated she did not fill out an incident report and said the event was not investigated.

The CAH did not identify and investigate Patient #14's blood testing anomaly.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the patient right to formulate an advance directive was upheld. This failure directly impacted 1 of 2 swing bed patients (Patient #3) whose records were reviewed, and had the potential to impact all swing bed patients admitted to the facility by affecting staff response in the case of a life threatening emergency. The findings include:

A facility policy titled Swing Beds, dated 10/19/16, stated "The issue of Advance Medical Directives will be addressed either by the Social Worker or the nursing staff at the time of admission, or when appropriate."

Patient #3 was an 84 year old female admitted to swing bed status on 2/22/17 for rehabilitation following a right hip fracture and repair.

The physician's admission note, dated 2/23/17, showed "Code Status: No Code Status Available." Further review of Patient #3's record did not show further action had been taken to address her wishes or code status.

In an interview on 6/07/17 at 3:00 P.M., the CNO said it was the providers responsibility to address advance directives with patients and the nursing staff did not offer education to patients regarding advance directives.

The facility failed to ensure the right to formulate advance directives was upheld.

Based on record reviews, policy review and staff interview, it was determined the facility failed to ensure an ongoing program of activities for 2 of 2 swing bed patients (Patients #3 and #4) whose closed records were reviewed. This resulted in the lack of recreational activities for swing bed patients, and had the potential to result in unmet patient needs. Findings include:

A facility policy titled Swing Bed Residents Services Provided, dated 10/19/16, stated "The following services are available, as needed, by patients to improve and maintain functioning:
1. Activities program, 2. Rehabilitation Services, 3. Dental Services, 4. Social Services/Discharge Planning."

1. Patient #3 was an 84 year old female admitted to swing bed status on 2/22/17 for rehabilitation following a right hip fracture and repair. During her 16 day admission there was no documentation of meaningful, planned activities that met her interests or addressed her psychosocial needs.

During an interview on 6/07/17 at 2:00 P.M., the CNO said there was no activity program available to patients at the facility.

2. Patient #4 was an 80 year old male who was admitted to swing bed status on 4/06/17 for comfort care and was discharged on 5/30/17. Patient #4 was assessed as "bedbound". During his 54 day admission there was no documentation of meaningful, planned activities that met his interests or addressed his psychosocial needs.

During an interview on 6/07/17 at 2:00 P.M., the CNO said there was no activity program available to patients at the facility.

Additionally, a physician's visit note in Patient #4's record, dated 5/01/17, stated "patient currently with minimal social contact. No programs available at [hospital's name] as not set up as a long term facility...expect patient would enjoy additional activities."

The facility failed to provide swing bed patients with an activity program.

Based on record review, policy review and staff interview, it was determined the CAH failed to complete a comprehensive assessment of the patients' needs, for 2 of 2 swing bed patients (Patients #3 and #4) whose closed records were reviewed. This resulted in lack of information necessary to develop a POC and provide services based on the individuals' status. Findings include:

A facility policy titled Swing Beds, dated 10/19/16, stated "A nursing assessment will be completed."

1. Patient #3 was an 84 year old female who was admitted to swing bed status on 2/22/17 after a right hip fracture. An initial nursing assessment was completed on 2/22/17. The assessment was not comprehensive. It did not address the following:
- Customary routine
- Mood and behavior patterns
- Psychosocial well being
- Activity pursuit

In an interview on 6/07/17 at 2:00 P.M., the CNO confirmed the lack of a comprehensive nursing assessment for Patient #3. She said the facility's EMR was designed for acute care patients and staff needed to modify certain areas to accommodate swing bed patient needs.

2. Patient #4 was an 80 year old male who was admitted to swing bed status on 4/06/17 for comfort care. An initial nursing assessment was completed on 4/06/17. The assessment was not comprehensive. It did not address the following:
- Customary routine
- Communication
- Psychosocial well being
- Activity pursuit
- Discharge potential

In an interview on 6/07/17 at 2:00 P.M., the CNO confirmed the lack of a comprehensive nursing assessment for Patient #4. She said the facility's EMR was designed for acute care patients and staff needed to modify certain areas of the record to accommodate swing bed patient needs.

Comprehensive assessments were not completed on patients.

Based on staff interview, policy review and record review, it was determined the CAH failed to ensure comprehensive care plans were developed for 2 of 2 Swing-bed patients (#3 and #4) whose closed records were reviewed. The lack of comprehensive care plans created the potential that care needs would be unmet. The findings include:

Mosby's Medical Dictionary, 2009, defined a nursing care plan as a "process to ensure that nursing care is consistent with the patient's needs and progress toward self care."

A facility policy titled Management and Evaluation of Patient's Care Plan, dated 10/19/16, stated "The development, management, and evaluation of a patient care plan, based on the physician's orders,constitute skilled nursing services when, in terms of the patient's physical or mental condition, these services require the involvement of skilled nursing personnel to meet the patient's medical needs, promote recovery, and insure medical safety."

1. Patient #3 was an 84 year old female, admitted to swing bed status on 2/22/17 for rehabilitation after a fall at home resulting in a right hip fracture and repair. She was discharged home on 3/10/17 after a 16 day stay at the facility.

Patient #3's admitting diagnoses included right femur fracture, COPD, chronic atrial fibrillation, and DVT prophylaxis with blood thinner therapy.

Her initial nursing assessment documented she needed full assistance with ambulation, toileting, and transfers, was on 1 L of oxygen to maintain saturations above 90%, had decreased appetite, had 2+ edema in both feet, required dressing changes for three surgical wounds, and was experiencing pain (level undocumented).

Patient #3 did not have a POC documented in her record.

A care plan was not developed to address potential problems identified in the initial assessment including, but not limited to, skin integrity, pain control, bleeding, incisional wound status, and cardiac status and respiratory support.

In an interview on 6/07/17 at 3:00 P.M., the CNO confirmed a care plan was not present to address Patient #3's present or potential areas of need.

2. Patient #4 was an 80 year old male, admitted to swing bed status on 4/06/17. He was discharged to another facility, on 5/30/17, after a 54 day stay at the facility. His admission assessment, performed by the mid level provider, documented Patient #4 was unable to stand, unable to ambulate, was completely bedbound due to weakness, had impaired hearing and eating, and had a flat affect with a diagnosed depressive disorder. It was also noted "patient has bandage covering tailbone area."

Patient #4's admitting diagnoses included severe depression, stable CHF, recent UTI (indwelling catheter in place), chronic back pain, and deconditioning.

Patient #4's POC, dated 4/10/17, documented one problem, a "risk for bleeding", with one nursing intervention of "fall prevention."

A care plan was not developed to address potential problems identified in the initial assessment including, but not limited to, skin integrity, hearing and eating impairments, indwelling urinary catheter, pain control, and mental status.

In an interview on 6/07/17 at 2:00 P.M., the CNO confirmed the care plan did not address Patient #4's present or potential areas of need.

The facility failed to ensure POCs were adequately developed for Patients #3 and #4.