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Based on Idaho administrative rules review, observation, and staff interview, it was determined the CAH failed to ensure video monitoring of patients was furnished in accordance with Idaho state law. This had the potential to affect the privacy of all patients who were video monitored in patient care areas. Findings include:

Idaho rules and minimum standards for hospitals 16.03.14.220 states, "09. Personal Privacy. The patient has the right to personal privacy, including the right to privacy during all personal care, including hygiene activities such as bathing, dressing, and toileting. This right includes the right to treatment with dignity during personal care. (7-1-19)...f. Monitors used for observing patients must not be visible or audible to unauthorized persons."

A tour of the CAH was conducted in the presence of the Compliance Officer on 7/08/19, beginning at 8:00 AM. During the tour, on the Medical/ Surgical unit, video cameras were noted in patient rooms 207, 208, and 216. The monitors used to view these cameras were located at the unit's nurses' station. These monitors were viewable from the patient side of the nurses' station and did not have a barrier to prevent unauthorized persons from viewing them.

The Compliance Officer was interviewed on 7/09/19, beginning at 12:00 PM. She stated administration had been working on a solution for making the monitors less viewable from visitors, but they had not fixed the issue yet. The Compliance Officer confirmed the monitors were viewable from the patient side of the nurses' station.

The CAH failed to ensure video monitoring of patients was furnished in accordance with Idaho state law.

2. Idaho rules and minimum standards for hospitals 16.03.14.220 states, "09. Personal Privacy. The patient has the right to personal privacy, including the right to privacy during all personal care, including hygiene activities such as bathing, dressing, and toileting. This right includes the right to treatment with dignity during personal care. (7-1-19)...c. When the hospital utilizes the continuous observation of patients, and/or video recording of patients, it must develop policies and procedures to direct staff in these activities. (7-1-19)."

A tour of the CAH was conducted in the presence of the Compliance Officer on 7/08/19, beginning at 8:00 AM. During the tour, on the Medical/ Surgical unit, video cameras were noted in patient rooms 207, 208, and 216.

The Compliance Officer was asked for a policy which governed the use of video monitoring, however, she stated the CAH had not developed one.

The CAH failed to ensure written policies and procedures for video monitoring in accordance with Idaho state law.

Based on medical record review, ED register review, observation, policy review, quality document review, and staff interview, it was determined the CAH failed to ensure emergency care was provided to meet the needs of 4 of 11 ED patients (#8, #9, #19, and #34) whose records were reviewed. This resulted in lack of clinical documentation, emergency medications and equipment which were not maintained, absent ED quality data, lack of ED ancillary staff supervision, and had the potential for poor clinical outcomes of all patients seeking emergency treatment at the CAH. Findings include:

1. The CAH failed to ensure consent, triage, and an MSE were documented for ED patients. Examples include:

a. Patient #19 was a 23 year old female who presented to the emergency room on 6/08/19, with a presenting diagnosis of abdominal pain.

The ED register documented Patient #19 was registered at 9:18 PM and had a discharge disposition of "LWBS" at 9:46 PM; 28 minutes after presenting to the ED. Patient #19's ED record did not include a consent for treatment. Patient #19's ED record did not include documentation of triage or an MSE. It could not be determined if Patient #19 was seen by a physician for the duration of her 28 minute ED stay.

Patient #19's medical record included a progress note dated 6/08/19, signed by the ED RN, which stated, "Patient arrived to ER stating she had fell a few hours prior and was worried about her baby. The patient is 34 weeks pregnant. Other then [sic] pain at the sight of the fall the patient is not having any other physical issues. The patients[sic] vitals are within normal ranges. The fetus's HR was assessed to be 168 BPM using the doppler. The patient is being sent home and told to return if any other symptoms occur or if the patient has any concerns. Patient teaching was given about precautions of falls, concerns to watch for, and to rest."

Patient #19's ED RN was interviewed on 7/10/19, beginning at 12:56 PM, and Patient #19's ED record was reviewed in her presence. She stated Patient #19 had come in to, "get her baby checked out" after a fall several hours prior. The ED RN stated she notified the ED physician and they assessed the patient and baby's fetal heart tones with a doppler in the ED. She stated the ED physician was with her in the room and spoke with Patient #19. The ED RN stated she was unaware the ED physician did not document Patient #19's MSE. She stated Patient #19 refused any other types of exam or further work-up after her baby's fetal heart tones were confirmed. The ED RN stated Patient #19 did not sign a refusal of care or AMA form. She stated she should have documented more about Patient #19 refusing care.

Patient #19's ED physician was interviewed via telephone on 7/10/19, beginning at 9:54 AM, and Patient #19's ED record was reviewed. He stated he believed he saw Patient #19 and performed an exam, but stated he was unsure if he documented this.

b. Patient #34 was a 30 year old female who was seen in the ED on 4/06/19, with a presenting diagnosis of back pain.

The ED register documented Patient #34 was registered at 8:01 AM and had a discharge disposition of "LWBS" at 12:28 PM; 267 minutes after presenting to the ED. Patient #34's ED record did not include a consent for treatment. Patient #34's ED record did not include documentation of triage or an MSE. It could not be determined if Patient #34 was seen by a physician or an RN for the duration of her 267 minute ED stay.

c. Patient #8 was a 45 year old female who was seen in the ED on 2/14/19, with a presenting diagnosis of leg pain and numbness.

The ED register documented Patient #8 was registered at 9:09 PM and had a discharge disposition of "LWBS" at 10:40 PM; 91 minutes after presenting to the ED. Patient #8's ED record did not include a consent for treatment. Patient #8's ED record did not include documentation of triage or an MSE. It could not be determined if Patient #8 was seen by a physician or an RN for the duration of her 91 minute ED stay.

d. Patient #9 was a 41 year old female who was seen in the ED on 1/31/19, with a presenting diagnosis of low blood pressure.

The ED register documented Patient #9 was registered at 3:17 PM and had a discharge disposition of "LWBS" at 3:36 PM; 19 minutes after presenting to the ED. Patient #9's ED record did not include a consent for treatment. Patient #9's ED record did not include documentation of triage or an MSE. It could not be determined if Patient #9 was seen by a physician or an RN for the duration of her 19 minute ED stay.

The Compliance Officer and interim DNS were interviewed together on 7/09/19, beginning at 12:53 PM, and the above ED medical records were reviewed in their presence. They confirmed the ED medical records did not include a documented triage or MSE. When asked if the CAH had policies for ED triage and MSE's, the Compliance Officer stated, "no." Additionally, the Compliance Officer and interim DNS confirmed the ED medical records did not include patients' consent for treatment.

The Admitting Coordinator was interviewed on 7/10/19, beginning at 8:18 AM. She confirmed all patients who presented to the ED must sign a consent for treatment as they are being registered.

The CAH failed to ensure consent, triage, and an MSE were documented for ED patients.

2. The CAH's ED did not triage and obtain consent for all patients who were seen.

The Admitting Coordinator was interviewed on 7/10/19, beginning at 8:38 AM. She stated she knew of several examples of patients who presented to the CAH's ED asking to be "checked" for issues such as minor pain and blood pressure. The Admitting Coordinator stated these patients were not formally triaged or registered, and did not sign consents to be treated.

An ED physician was interviewed on 7/10/19, beginning at 9:03 AM. He stated he knew of several examples of patients who presented to the CAH's ED asking to be "checked," as well. The ED physician stated, "sometimes patients come in to be checked out without my knowing."

An ED RN was interviewed on 7/10/19, beginning at 12:56 PM. She stated she knew of several examples of patients who presented to the CAH's ED asking to be "checked" for issues. The ED RN stated the patients were not formally triaged or registered, and did not sign consents to be treated.

The Compliance Officer was interviewed on 7/11/19, beginning at 12:42 PM. She stated she was unaware of patients presenting to the CAH's ED to be "checked." The Compliance Officer stated it was her expectation that patients who asked to be evaluated would be registered, consented, and triaged accordingly. However, she confirmed the CAH did not have a triage policy.

The CAH's ED did not triage, registered, and obtain consent for all patients who were seen.

3. Refer to C-204, as it relates to the failure of the CAH to ensure emergency medical equipment was maintained.

4. Refer to C-335, as it relates to the failure of the CAH to ensure an evaluation was done to determine whether the utilization of ED services was appropriate.

The cumulative effect of these systemic practices prevented the CAH from providing emergency care based upon patients' needs.



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

A CAH policy "Emergency Crash Carts and Equipment-Surgical Services," approved 10/28/16, stated, "Emergency drugs and supplies, for use in medical emergencies only, shall be immediately available at each patient care unit or service area." This policy was not followed.

1. A tour of the ED was conducted in the presence of the interim DNS on 7/09/19, beginning at 8:09 AM. The following emergency medical equipment had expired:

- Two ABG kits had expired on 6/2019

- One I/O start kit had expired on 12/2018

- Two bovies had expired; 1 on 4/2019 and 1 on 11/2018

The interim DNS was interviewed on 7/09/19, beginning at 8:09 AM, and he confirmed the emergency medical equipment had expired.

ED emergency medical equipment had expired.

2. A tour of the Medical/ Surgical unit was conducted in the presence of the Compliance Officer on 7/09/19, beginning at 8:15 AM. The unit had 1 emergency crash cart. The following emergency medical equipment had expired:

- "Quick Trach" Criothyrotomy 2.0 and 4.0 sets had expired on 5/2019

The Compliance Officer was interviewed on 7/09/19, beginning at 8:15 AM, and she confirmed the emergency medical equipment had expired.

Medical/ Surgical emergency medical equipment had expired.

Based on medical record review, observation, and staff interview, it was determined the CAH failed to ensure essential patient care equipment was maintained in safe operating condition. This had the potential for critical equipment to malfunction when needed. Findings include:

1. Patient #19 was a 23 year old female who presented to the emergency room on 6/08/19, with a presenting diagnosis of abdominal pain.

Patient #19's medical record included a progress note dated 6/08/19, signed by the ED RN, which stated, "Patient arrived to ER stating she had fell a few hours prior and was worried about her baby. The patient is 34 weeks pregnant. Other then [sic] pain at the sight of the fall the patient is not having any other physical issues. The patients[sic] vitals are within normal ranges. The fetus's HR was assessed to be 168 BPM using the doppler. The patient is being sent home and told to return if any other symptoms occur or if the patient has any concerns. Patient teaching was given about precautions of falls, concerns to watch for, and to rest."

A tour of the ED was conducted in the presence of the interim DNS on 7/10/19, beginning at 8:49 AM. During the tour, the ED's sole doppler used for fetal heart tones did not have a biomed tracking number or "last checked" date. It could not be determined if the doppler had ever been serviced by the biomedical contract vendor or if it was operating within optimal parameters.

The interim DNS was interviewed on 7/10/19, beginning at 8:49 AM, and he confirmed it could not be determined if the doppler had ever been serviced.

ED patient care equipment was not maintained.

2. A tour of the OR's central sterile area was conducted in the presence of the ST on 7/11/19, beginning at 8:53 AM. During the tour, the sole Branson US ultrasonic machine had a biomed tracking number with a "last checked" date of 11/2016. It could not be determined if the ultrasonic machine had been serviced since this date or if it was operating within optimal parameters.

The ST was interviewed on 7/11/19, beginning at 8:53 AM, and she confirmed it could not be determined if the ultrasonic machine had been serviced since 11/2016.

Central Sterile patient care equipment was not maintained.

3. A tour of the Medical/ Surgical unit was conducted in the presence of Compliance Officer on 7/11/19, beginning at 11:22 AM. During the tour, the sole AccuVein machine had a biomed tracking number with a "last checked" date of 1/2018. It could not be determined if the AccuVein machine had been serviced since this date or if it was operating within optimal parameters.

The Compliance Officer was interviewed on 7/11/19, beginning at 11:22 AM, and she confirmed it could not be determined if the AccuVein machine had been serviced since 1/2018.

Medical/ Surgical patient care equipment was not maintained.

Based on medical record review and staff interview, it was determined the CAH failed to ensure the ED CNA was supervised by the ED RN for 1 of 1 pregnant ED patient (Patient #19), whose record was reviewed. This had the potential for missed opportunities to evaluate delegated patient care. Findings include:

Patient #19 was a 23 year old female who presented to the emergency room on 6/08/19, with a presenting diagnosis of abdominal pain.

Patient #19's medical record included a progress note dated 6/08/19, signed by the ED RN, which stated, "Patient arrived to ER stating she had fell a few hours prior and was worried about her baby. The patient is 34 weeks pregnant. Other then [sic] pain at the sight of the fall the patient is not having any other physical issues. The patients[sic] vitals are within normal ranges. The fetus's HR was assessed to be 168 BPM using the doppler. The patient is being sent home and told to return if any other symptoms occur or if the patient has any concerns. Patient teaching was given about precautions of falls, concerns to watch for, and to rest." Patient #19's medical record did not include vital signs or a consent for treatment.

The ED RN was interviewed on 7/10/19, beginning at 12:56 PM, and Patient #19's medical record was reviewed in her presence. When asked if vital signs or a consent for treatment was obtained for Patient #19, the ED RN stated those tasks were delegated to the ED CNA. She stated she was unaware the ED CNA had not completed those 2 delegated tasks and confirmed she did not check to ensure they were documented.

The ED RN failed to supervise the ED CNA.

Based on observation, policy review, and staff interview, it was determined the CAH failed to ensure outdated medications were not available for patient use. This had the potential for patients' health and safety to be compromised in the event of a medical emergency. Findings include:

A CAH policy "Emergency Crash Carts and Equipment-Surgical Services," approved 10/28/16, stated, "Emergency drugs and supplies, for use in medical emergencies only, shall be immediately available at each patient care unit or service area." This policy was not followed.

1. A tour of the Medical/ Surgical unit was conducted in the presence of the Compliance Officer on 7/09/19, beginning at 8:15 AM. The unit had 1 emergency crash cart. The following emergency medications had expired:

- Nitrostat 0.4 mg (a cardiac medication) tabs expired 11/2018

- Metoprolol tartrate 5 mg/5 ml (a cardiac medication) solution expired 1/2019

The Compliance Officer was interviewed on 7/09/19, beginning at 8:15 AM, and he confirmed the emergency medications had expired.

Medical/ Surgical emergency medications had expired.

2. A tour of the ED was conducted in the presence of the interim DNS on 7/09/19, beginning at 8:09 AM. During the tour, Lasix (a diuretic medication) was found in the emergency crash cart in Trauma Room 1 with an expiration date of 6/2019.

The interim DNS was interviewed on 7/09/19, beginning at 8:09 AM, and she confirmed the emergency medication had expired.

ED emergency medication had expired.

Based on medical record review and staff interview, it was determined the CAH failed to ensure medical record QIO information was accurately documented. This resulted in incorrect QIO information being provided to all patients receiving care at the CAH. Findings include:

Admission paperwork provided to, and signed by, patients included "An Important Message From Medicare About Your Rights" form. The form included a section titled "Name of QIO" which stated "Livanta LLC." Additionally, the form included a section titled "Telephone Number of QIO" which stated "1-877-588-1123." However, the correct QIO for the CAH was "Kepro" and its telephone number was "1-888-305-6759."

The Compliance Officer was interviewed on 7/09/19, beginning at 12:53 PM, and patients' admission paperwork was reviewed in her presence. She stated she was unaware the CAH's QIO had recently changed and confirmed the information provided to patients was incorrect.

The CAH failed to provide patients with accurate QIO information.

Based on review of quality documents and staff interview, it was determined the CAH failed to ensure an evaluation was done to determine whether the utilization of ED services was appropriate. This resulted in a lack of feedback to persons responsible for the operation of the CAH. Findings include:

QAPI data was reviewed in the presence of the Compliance Officer on 7/10/19, beginning at 9:54 AM. The CAH's QAPI program failed to evaluate and/or document the following service utilization:

1. A quality indicator titled "EMTALA" was documented, but did not have any recorded data for 2019. It could not be determined if the CAH was actively evaluating potential EMTALA violation cases or gathering aggregate data to determine ongoing EMTALA compliance.

2. A quality indicator for the ED titled "LWBS" documented monthly percentages as goals, however, there was no archived record of the data used to extrapolate these findings. It could not be determined how the QAPI program came to its conclusions regarding monthly reported LWBS goals due to lack of evidence.

The Compliance Officer was interviewed on 7/10/19, beginning at 9:54 AM. She stated the CAH's QAPI program had gone through large changes in the last year to better report on the scope and detail of its services. The Compliance Officer confirmed the QAPI program failed to document EMTALA related metrics. Additionally, she confirmed the QAPI program failed to retain data used to extrapolate findings related to ED LWBS patients.

The CAH failed to ensure an evaluation was done to determine whether the utilization of ED services was appropriate.

Based on OPO agreement review and staff interview, it was determined the CAH failed to ensure a valid agreement with an OPO. This had the potential to interfere with patient and family donor options regarding to organ donation for all CAH patients. Findings include:

The CAH's OPO agreement "ORGAN RECOVERY AGREEMENT," dated 7/15/13, was reviewed. The agreement was written for, and referenced, CMS Conditions of Participation for Hospitals at 42 CFR 482.45, not CMS Conditions for Participation for Critical Access Hospitals at 42 CFR 485.643. The OPO agreement did not address the correct regulatory requirements for a Critical Access Hospital.

The CEO was interviewed on 7/10/19, beginning at 2:41 PM, and the OPO agreement was reviewed in her presence. She confirmed the OPO agreement referenced the wrong CMS regulatory set. The CEO notified the contracted OPO of the invalid agreement. Per the CEO, the OPO representative stated they would correct the issue.

The CAH failed to incorporate a valid agreement with an OPO.