HospitalInspections.org

Based on review of policy table of contents, Governing Body meeting minutes, annual evaluation, and staff interview, it was determined the CAH failed to ensure annual evaluation of its health care policies was performed. This prevented the CAH from determining whether its policies were complete and reflected the care staff provided to patients. Findings include:

The CAH's policy table of contents included 232 approved, active policies which ranged from acute care to billing practices. Of the 232 active policies, the most recent review date was May 2014. It was unclear if the CAH's policy structure, including all active policies, had been reviewed in the past 6.5 years.

Governing Body meeting minutes from 10/16/19 to 10/21/20, were reviewed. The meeting minutes did not include documented review of the 232 active policies.

The CAH's most recent annual program evaluation, dated 3/11/20, was reviewed. The evaluation included 6 specific policies which were either reviewed or created, which included:

- Sedation
- Patient Care
- Patient Call Back
- Phone Down Time
- Sliding Fee Schedule
- Mandatory Flu Vaccine

These 6 policies were not included in the CAH's policy table of contents. It could not be determined how these policies were being catalogued and/or indexed. Additionally, the evaluation did not include documented review of the 232 active policies.

The CEO was interviewed on 11/19/20, beginning at 3:21 PM, and the CAH's policy table of contents was reviewed in his presence. He confirmed the CAH's active policies "had not been reviewed in several years, but would be done soon."

The CAH failed to ensure annual evaluation of its health care policies was performed.

Based on annual evaluation review and staff interview, it was determined the CAH failed to ensure its quality assurance program evaluated all patient care services affecting patient health and safety. This failure prevented the CAH from analyzing all services provided to ensure patients' needs were met. Findings include:

The CAH's most recent annual evaluation, dated 3/11/20, was reviewed. The evaluation did not include documented review of the following patient services:

- Telemedicine Services

- Dietary Services

- Social Services

Additionally, the evaluation included ED metrics such as AMA, transfers, admissions, and discharges. However, it did not include LWBS patients. It could not be determined how the CAH tracked and analyzed this data set.

The CNO was interviewed on 11/18/20, beginning at 10:33 AM, and the CAH's annual evaluation was reviewed in her presence. She confirmed telemedicine, dietary, social services, and LWBS patients were not currently part of the CAH's program evaluation.

The CAH failed to ensure its quality assurance program evaluated all patient care services affecting patient health and safety.

Based on medical record review, policy review, Idaho statutes review, and staff interview, it was determined the CAH failed to ensure compliance with Idaho state law related to potential neglect of vulnerable adults for 2 of 3 patients (#20 and #25) who left the CAH AMA, and whose records were reviewed. This resulted in potential patient neglect not being reported to appropriate agencies for further investigation. Findings include:

"IDAHO STATUTES TITLE 39 HEALTH AND SAFETY CHAPTER 53 ADULT ABUSE, NEGLECT AND EXPLOITATION ACT," updated 7/01/20, states "39-5303. Duty to report cases of abuse, neglect or exploitation of vulnerable adults. (1) Any physician, nurse, employee of a public or private health facility, or a state licensed or certified residential facility serving vulnerable adults, medical examiner, dentist, osteopath, optometrist, chiropractor, podiatrist, social worker, police officer, pharmacist, physical therapist, or home care worker who has reasonable cause to believe that a vulnerable adult is being or has been abused, neglected or exploited shall immediately report such information to the commission. Provided however, that nursing facilities defined in section 39-1301(b), Idaho Code, and employees of such facilities shall make reports required under this chapter to the department. When there is reasonable cause to believe that abuse or sexual assault has resulted in death or serious physical injury jeopardizing the life, health or safety of a vulnerable adult, any person required to report under this section shall also report such information within four (4) hours to the appropriate law enforcement agency."

A CAH policy, "Adult Abuse, Vulnerable," revised January 2011, was reviewed. The policy instructed staff to report suspected patient abuse and/or neglect to law enforcement, but did not include mandated reporting duties to Idaho Adult Protective Services. It could not be determined what the CAH's expectations and instructions for reporting suspected vulnerable adult abuse/neglect to APS were per state law.

The CAH's policy and Idaho statute were not followed. Examples include:

1. Patient #20 was a 52 year old male who was admitted on 9/01/20, with a primary diagnosis of right sided weakness and history of ETOH abuse. He was first admitted to observation and then swing bed status on 9/03/20. Patient #20 left the hospital AMA on 9/03/20.

Patient #20's medical record included an ED patient assessment, dated 9/01/20, signed by a PA, which stated, "He is known to have 2 - 3 people who live with him and are present to provide care - however [Patient #20] was found with a bucket tied to him for [sic] assist with his bowels the first time EMS responded last night. The second time EMS responded, he was on a frying pan used as a bedpan and was covered in feces, urine."

Patient #20's medical record included a progress note, dated 9/02/20, signed by a PA, which stated, "[Patient #20] does have a roommate, but admits to very little help at home and wonders whether he is safe there."

Patient #20's medical record included a physician progress note, dated 9/03/20, signed by his attending physician, which stated, "suicidal risk...Also sees a therapist as far as depression and suicidal thoughts he has had in the past. It should be noted that he failed this suicide evaluation screen here in the hospital and does have a personal care attendant. Today is Saturday. Will have him seen by social worker on Monday to reassess the status. Hopefully, he can come off any sort of personal care tended [sic] need...Will ask Social Services to be involved as far as alcoholism and suicide risk...Total encounter time today was 65 minutes including outside record review and discussion with nursing staff related to suicidal risk concerns."

Patient #20's medical record included a nursing note, dated 9/03/20, signed by an RN, which stated, "Pt discharged. Myself, another RN, and the Pts roommate attempted to convince the Pt that staying the night and continuing to search for a rehab to transfer him to in the AM would be a better plan. Pt refused. While going over DC paperwork Pt was upset, stated that he witnessed 'bad things' going on in the hospital. Stated that someone came into his room and "drug a needle across his forehead." Assume that a staff member was taking his temporal temperature. Also stated that he 'saw 3 kids, not wearing masks, brake [sic] into the closet across the hallway, and steel [sic] some coats.' Pt seemed confused about what was going on during the day. Stated that he thought 'we were going to kill him and blame it on COVID.' Stated that he 'did not feel safe' here. Pt required 2 staff members for transfer to the wheelchair, very weak. Also required 2 staff to help Pt into his roommates [sic] car."

Patient #20's medical record included "Discharge Instructions," dated 9/03/20, which stated, "Condition: Weak. Discharging against advice."

Patient #20's medical record did not include a CAH AMA form. It is unclear if Patient #20 signed himself out AMA, if he was competent to do so, or who informed him of the risks for leaving AMA.

CAH medical staff did not document if they notified law enforcement per policy or APS per Idaho statute regarding Patient #20.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and Patient #20's medical record was reviewed in her presence. She confirmed CAH medical staff did not document if they notified law enforcement per policy or APS per Idaho statute regarding Patient #20. The CNO stated APS should have been contacted. Additionally, she confirmed the CAH's abuse policy did not include a mechanism for informing Idaho APS regarding suspected vulnerable adult abuse and neglect.

The PA who documented Patient #20's ED assessment was interviewed on 11/19/20, beginning at 2:37 PM, and Patient #20's medical record was reviewed in her presence. She confirmed she did not document if she notified law enforcement per policy or APS per Idaho statute regarding Patient #20.

The CAH's Medical Director, who was attending Patient #20 while on swing bed status, was interviewed on 11/19/20, beginning at 2:37 PM, and Patient #20's medical record was reviewed in his presence. He stated he remembered contacting law enforcement to do a welfare check on Patient #20 after he left the CAH. The Medical Director stated he believed he documented this in Patient #20's RHC medical record, not his CAH medical record. He stated he did not contact APS regarding Patient #20. The Medical Director stated Patient #20 was transported to Boise, ID by his mother for rehab/SNF admission shortly after leaving the CAH, but confirmed this was not documented.

The CAH failed to ensure compliance with State law related to potential neglect of Patient #20.

2. Patient #25 was a 63 year old female who was admitted on 9/28/20, with a primary diagnosis of ETOH intoxication.

Patient #25's medical record included an ED patient assessment, dated 9/28/20, signed by a PA, which stated, "Today when EMS evaluated the patient, she was quite disheveled, her home was dirty and was actually soiled in her own urine and feces."

The PA did not document if he notified law enforcement per policy or APS per Idaho statute regarding Patient #20.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and Patient #25's medical record was reviewed in her presence. She confirmed the PA did not document if he notified law enforcement per policy or APS per Idaho statute regarding Patient #20. The CNO stated APS should have been contacted.

The CAH failed to ensure compliance with State law related to potential neglect of Patient #25.

Based on observation, medical record review, policy review, Idaho statues review, document review, personnel file review, medical staff bylaws review, and staff interview, it was determined the CAH's organizational structure was insufficient to ensure vital programs were defined, directed, and maintained. This resulted in a lack of leadership and direction to CAH staff. Findings include:

1. Refer to C-337, as it relates to the CAH's failure to ensure its quality assurance program evaluated all patient care services affecting patient health and safety.

2. Refer to C-810, Condition of Participation: Compliance with Federal, State, and Local Laws and Regulations, as it relates to the CAH's failure to ensure compliance with Idaho state law related to suspected neglect of vulnerable adults.

3. Refer to C-962, as it relates to the CAH's failure to maintain oversight of the CAH's operation and program to ensure accountability of staff and safe patient care.

4. Refer to C-1004, Condition of Participation: Provision of Services, and associated standard level deficiencies, as they relate to the CAH's failure to ensure directed patient care by CAH staff to meet patients' needs was provided in accordance with appropriately written policies.

5. Refer to C-1100, Condition of Participation: Clinical Records, and associated standard level deficiencies, as they relate to the CAH's failure to ensure clinical records were complete, accurate, and safeguarded from loss.

6. Refer to C-1400, Condition of Participation: Discharge Planning, as it relates to the CAH's failure to have an effective discharge planning process that focuses on the patient's goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care.

7. Refer to C-1616, as it relates to the CAH's failure to provide and monitor medically-related social services.

The cumulative effect of these systemic issues seriously impeded the ability of the CAH to provide and document quality care.

Based on medical record review, personnel file review, medical staff bylaws review, policy review, and staff interview, it was determined the Governing Body failed to maintain oversight of the CAH's operation and program to ensure accountability of staff and safe patient care. This resulted in incomplete and missing policies, lack of HR oversight of staff, and non-approved medical staff bylaws. Findings include:

1. The Governing Body failed to ensure system-wide policies were created and/or active and executed for patient care delivery. Examples include:

a. A CAH policy, "CONSENTS," revised January 2011, stated, "Informed consent should be obtained and a special consent form should be signed when a patient is to undergo any procedures, which, in the opinion of the Provider, involves additional risks to the patient...Blood Products Administration." This policy was not followed.

The Laboratory Manager was interviewed on 11/19/20, beginning at 1:26 PM. When asked for blood products administration consent, she stated the CAH did not have one. The Laboratory Manager stated most blood product administration was done in the ED during emergency issues where patients did not have the capacity to consent. She stated the CAH did not have a consent process for non-emergency patients and/or emergency patients who had the capacity to consent. The Laboratory Manager stated, "The Red Cross did not provide us with a consent."

The CNO was interviewed on 11/19/20, beginning at 1:26 PM. She confirmed the CAH should have a consent process in place for non-emergency patients and/or emergency patients who had the capacity to consent. The CNO stated the CAH did not follow its consent policy.

The Governing Body failed to provide informed consent to patients prior to blood product administration per CAH policy.

b. The CAH's policy table of contents included 232 approved, active policies which ranged from acute care to billing practices. The CAH did not have social services policies to include their roles, responsibilities, services provided, scope and availability, and processes. It could not be determined how social services, especially for psychiatric, swing bed, and difficult discharge planning patients, were integrated in to the CAH's patient care delivery system.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and the CAH's policy table of contents was reviewed in her presence. She confirmed the CAH did not have approved, active policies for social services. The CNO stated the sole social worker primarily worked in their affiliated RHC and would come to the CAH to provide services as needed. Additionally, the CNO stated the social worker would take part in the interdisciplinary committee for swing bed patients, but confirmed this was not documented.

The Governing Body failed to ensure social services policies were approved and active.

2. The CAH's medical staff bylaws, dated 7/13/17, were reviewed. They included a page for dates and signatures of the Medical Director, CAH Administrator, and Board of Trustees Chairman to demonstrate legal adoption and approval of the bylaws. This page was blank. It could not be determined if the CAH's medical staff operated under approved bylaws.

The CEO was interviewed on 11/19/20, beginning at 3:21 PM, and the CAH's medical staff bylaws were reviewed in his presence. When asked if the CAH's medical staff was currently bound to the 2017 bylaws, he stated, "yes." The CEO confirmed the 2017 bylaws were not signed and stated the last known approved and signed bylaws were from 2014.

The Governing Body failed to ensure the CAH's medical staff operated under current, approved medical staff bylaws.

3. The CAH's policy table of contents included 232 approved, active policies which ranged from acute care to billing practices. The CAH did not have comprehensive HR policies to include staff background checks, job descriptions, orientation, education/training, or performance evaluations. Other than its employee licensure policy, it was unclear how the Governing Body ensured HR oversight and accountability of its staff to ensure patient care was provided safely and effectively.

Staff personnel files were requested by surveyors on 11/16/20, beginning at 2:36 PM. Staff personnel files were requested by surveyors a second time on 11/17/20, beginning at 8:00 AM. Staff personnel files were requested by surveyors a third time on 11/17/20, beginning at 2:00 PM. Staff personnel files were requested by surveyors a fourth time on 11/18/20, beginning at 8:00 AM, and the Business Manager and HR Director stated there were issues with HR documentation. The Business Manager stated the individual previously responsible for HR oversight had not kept accurate records and some personnel file information was either not tracked or not documented. Surveyors were provided what personnel file documentation the HR department had on 11/19/20, beginning at 8:00 AM.

CAH staff personnel files were incomplete. Examples include:

a. Staff A was a laboratory technician who was hired on 10/22/18. Staff A's personnel file did not include COVID-19 specific education or an orientation to her job duties.

b. Staff C was a CNA who was hired on 12/26/18. Staff C's personnel file did not include a criminal background check, orientation to her job duties, or performance evaluation.

c. Staff D was a Physical Therapist who was hired on 5/01/06. Staff D's personnel file did not include a criminal background check.

d. Staff E was a radiology technician who was hired on 1/08/19. Staff E's personnel file did not include a criminal background check or orientation to her job duties.

e. Staff F was an EMT who was hired on 3/29/29. Staff F's personnel file did not include a criminal background check or orientation to his job duties.

f. Staff G was an RN who was hired on 6/29/20. Staff G's personnel file did not include a criminal background check or orientation to his job duties.

g. Staff H was a housekeeper who was hired on 6/24/20. Staff H's personnel file did not include orientation to her job duties or COVID-19 specific education.

h. Staff I was a dietary manager who was hired on 8/25/20. Staff I's personnel file did not include a criminal background check, orientation to his job duties, or COVID-19 specific education.

The Business Manager and HR Director were interviewed together on 11/19/20, beginning at 11:45 AM, and staff personnel files were reviewed in their presence. They confirmed the tracking and oversight of personnel files were not complete. The HR Director stated there were HR policies which were included in new employee handbooks. When asked if he knew if the employee handbook policies related to HR were included and indexed as part of the CAH's policies, the HR Director stated he was unsure.

The CNO was interviewed on 11/19/20, beginning at 3:52 PM. When asked if the HR policies of the new employee handbook were considered part of the CAH's policy system, and subjected to annual review, she stated she did not believe so.

The Governing Body failed to ensure HR oversight and accountability of CAH staff.

Based on personnel roster review and staff interview, it was determined the CAH failed to document supervision of EMT's and CNA's by professional staff. This had the potential for missed opportunities to evaluate patient care. Findings include:

The CAH's personnel roster was reviewed and included 9 CNA's and 2 EMT's.

The CNO was interviewed on 11/18/20, beginning at 3:25 PM. When asked who provided supervision of EMT's and CNA's, the CNO stated the RN and/or medical staff. When asked if there was a policy which directed ancillary personnel supervision by professional staff, she stated no. When asked if supervision of EMT's and CNA's by professional staff was documented, she stated no. The CNO stated there was not a mechanism in the CAH's EMR to capture ancillary staff supervision, nor was it documented on paper.

The CAH failed to document supervision of EMT's and CNA's by professional staff.

Based on observation, medical record review, policy review, document review, and staff interview, it was determined the CAH failed to ensure directed patient care by CAH staff to meet patients' needs was provided in accordance with appropriately written policies. This resulted in fragmented patient care due to inconsistent CAH policies and had the potential for poor patient outcomes for all patients receiving care at the CAH. Findings include:

1. Refer to C-1006, as it relates to the CAH's failure to ensure healthcare services were provided in accordance with appropriately written policies.

2. Refer to C-1016, as it relates to the CAH's failure to follow established standards of practice in management of storage temperatures for medications.

3. Refer to C-1046, as it relates to the CAH's failure to meet the needs of patients.

4. Refer to C-1049, as it relates to the CAH's failure to ensure all medications were administered to patients by an RN or under the supervision of an RN.

5. Refer to C-1056, as it relates to the CAH's failure to ensure visitation rights were provided to each patient or his/her representative.

The cumulative effect of these negative systemic practices impeded the ability of the CAH to provide services of consistent and safe quality.

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to ensure healthcare services were provided in accordance with appropriately written policies for 21 of 34 patients (#'s 1 - 20 and 25), whose records were reviewed. This resulted in services not being furnished in a consistent manner, and had the potential to result in avoidable, adverse patient outcomes. Findings include:

1. CAH policies were not followed. Examples include:

a. A CAH policy, "Suicidal Patient: Admission and Precautions," undated, stated, "Arrangements for mental health evaluation by a Designated Mental Examiner are to be made as soon as possible. Provider is to contact Boise Health and Welfare Mental Health at (208) 334-0800 or after hours the Mobile Crisis Line at (800) 600-6474...A written order is necessary for continuation of suicide precautions...Document on Nursing Flow Sheet at least every 60 minutes and with any change of behavior, using objective observations of emotional status." This policy was not followed.

Patient #20 was a 52 year old male who was admitted on 9/01/20, with a primary diagnosis of right sided weakness and history of ETOH abuse. He was first admitted to observation and then swing bed status on 9/03/20. Patient #20 left the hospital AMA on 9/03/20.

Patient #20's medical record included a physician progress note, dated 9/03/20, signed by his attending physician, which stated, "suicidal risk...Also sees a therapist as far as depression and suicidal thoughts he has had in the past. It should be noted that he failed this suicide evaluation screen here in the hospital and does have a personal care attendant [1-to-1 sitter]. Today is Saturday. Will have him seen by social worker on Monday to reassess the status. Hopefully, he can come off any sort of personal care tended [sic] need...Will ask Social Services to be involved as far as alcoholism and suicide risk...Total encounter time today was 65 minutes including outside record review and discussion with nursing staff related to suicidal risk concerns." Patient #20 signed himself out AMA the evening of 9/03/20.

Patient #20's medical record did not include documentation a DE was contacted by his physician or if a DE was involved in his case. His medical record did not include an order for suicide precautions or an order for his 1-to-1 sitter. Patient #20's medical record did not include a nursing flow sheet of emotional status observations every 60 minutes. It was unclear how Patient #20 was kept safe prior to signing himself out of the CAH AMA, or whether he was competent to do so.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and Patient #20's medical record was reviewed in her presence. She confirmed Patient #20's medical record did not include documentation a DE was contacted by his physician or involved in his case, suicide precaution orders, or nursing flow sheet of emotional status observations every 60 minutes. The CNO stated the involvement of a DE at the CAH had been an ongoing challenge due to its geographical location. She confirmed Patient #20's medical record should have included additional documentation and clarity as to his mental status. The CNO confirmed CAH policy was not followed.

CAH staff did not follow their suicidal patient policy.

b. A CAH policy, "Patient Complaint Resolution Process," dated 8/12/04, stated, "Staff will refer any patient with a complaint to the appropriate Director of that area...". This policy was not followed.

Patient #20 was a 52 year old male who was admitted on 9/01/20, with a primary diagnosis of right sided weakness and history of ETOH abuse. He was first admitted to observation and then swing bed status on 9/03/20. Patient #20 left the hospital AMA on 9/03/20.

Patient #20's medical record included a nursing narrative, dated 9/03/20, signed by an RN, which stated, "While going over DC paperwork Pt was upset, stated that he witnessed 'bad things' going on in the hospital."

The CAH's complaint log from November 2019 to November 2020 was reviewed. Patient #20's complaint was not documented, tracked, or investigated. It could not be determined if Patient #20's complaint was addressed by staff.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and Patient #20's medical record was reviewed in her presence. She confirmed Patient #20's complaint was not documented, tracked, or investigated. The CNO confirmed CAH policy was not followed.

CAH staff did not follow their complaint policy.

c. A CAH policy, "Incident Reports," dated June 2017, stated, "A significant incident is defined as any incident that is unexpected or has an unexpected outcome. All employees, contract personnel, volunteers, and/or agents of CMC will follow the Incident Reporting policy...The employee involved in, discovering, or responding to the incident will complete the CMC Incident Report form." This policy was not followed.

Patient #20 was a 52 year old male who was admitted on 9/01/20, with a primary diagnosis of right sided weakness and history of ETOH abuse. He was first admitted to observation and then swing bed status on 9/03/20. Patient #20 left the hospital AMA on 9/03/20.

Patient #20's medical record included a nursing narrative, dated 9/03/20, signed by an RN, which stated, "[Patient #20] stated that someone came into his room and 'drug a needle across his forehead.'

The CAH's incident report log from November 2019 to November 2020 was reviewed. Patient #20's incident was not documented, tracked, or investigated. It could not be determined if Patient #20's incident was addressed by staff.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and Patient #20's medical record was reviewed in her presence. She confirmed Patient #20's incident was not documented, tracked, or investigated. The CNO confirmed CAH policy was not followed.

CAH staff did not follow their incident report policy.

d. A CAH policy, "DISCHARGE of the Patient," dated May 2014, stated, "Patients Leaving Against Medical Advice (AMA)...Patient may leave against medical advice. Every attempt should be made to notify the Provider [sic] have patient sign the Refusal of Further Treatment form prior to elopement." This policy was not followed.

i. Patient #20 was a 52 year old male who was admitted on 9/01/20, with a primary diagnosis of right sided weakness and history of ETOH abuse. He was first admitted to observation and then swing bed status on 9/03/20. Patient #20 left the hospital AMA on 9/03/20.

Patient #20's medical record included a "discharge condition," dated 9/03/20, which stated, "Condition: Weak. Discharging against advise [sic]." Patient #20's medical record did not include a "Refusal of Further Treatment" form. It could not be determined if the risks of leaving the CAH AMA were discussed with Patient #20.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and Patient #20's medical record was reviewed in her presence. She confirmed Patient #20's medical record did not include a "Refusal of Further Treatment" form. The CNO confirmed CAH policy was not followed.

CAH staff did not follow their AMA policy.

ii. Patient #25 was a 63 year old female who was admitted on 9/28/20, with a primary diagnosis ETOH intoxication. She left the hospital AMA that same day.

Patient #25's medical record included an "ED Course," narrative, dated 9/28/20, signed by a PA, which stated, "...would like to discharge home AGAINST MEDICAL ADVICE. Subsequently patient signed AGAINST MEDICAL ADVICE paperwork and she left in the company of 2 acquaintances." Patient #25's medical record did not include "AMA paperwork" or a "Refusal of Further Treatment" form. It could not be determined if the risks of leaving the CAH AMA were discussed with Patient #25.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and Patient #25's medical record was reviewed in her presence. She confirmed Patient #25's medical record did not include a "Refusal of Further Treatment" form. The CNO confirmed CAH policy was not followed.

CAH staff did not follow their AMA policy.

e. A CAH policy, "DISCHARGE of the Patient," dated May 2014, stated, "Patient will have a Provider order and a discharge plan prior to discharge." This policy was not followed.

Twenty inpatient records for Patient #'s 1 - 20 were reviewed and did not include discharge plans. It could not be determined what discharge planning was created and executed for these patients prior to them leaving the CAH.

The CNO was interviewed on 11/20/20, beginning at 8:20 AM, and the above patients' medical records were reviewed in her presence. She stated the CAH's current EMR system did not have the ability to create patient discharge planning. The CNO stated the CAH's EMR vendor informed them they would not be doing a system upgrade to include discharge planning. She stated staff did not document discharge planning outside the purview of the CAH's EMR system, such as paper charting. The CNO confirmed CAH policy was not followed.

CAH staff did not follow their discharge policy.

Patient #20 was a 52 year old male who was admitted on 9/01/20, with a primary diagnosis of right sided weakness and history of ETOH abuse. He was first admitted to observation and then swing bed status on 9/03/20. Patient #20 left the hospital AMA on 9/03/20.

f. A CAH policy, "Inpatient/ Outpatient/ Swing-Bed Services," revised May 2014, stated, "Skilled Swing-Bed...Discharge planning will begin on the day of admission." This policy was not followed.

Three of 3 swing-bed medical records reviewed for Patient #2, #18, and #20 did not include discharge planning. It could not be determined what discharge planning was created and executed for these patients prior to them leaving the CAH.

The CNO was interviewed on 11/20/20, beginning at 8:20 AM, and the above patients' medical records were reviewed in her presence. She stated the CAH's current EMR system did not have the ability to create patient discharge planning. The CNO stated the CAH's EMR vendor informed them they would not be doing a system upgrade to include discharge planning. She stated staff did not document discharge planning outside the CAH's EMR system, such as paper charting. The CNO confirmed CAH policy was not followed.

CAH staff did not follow their inpatient/outpatient/swing-bed policy.

2. CAH policies were not appropriately written. Examples include:

a. A CAH policy, "Patient Complaint Resolution Process," dated 8/12/04, stated, "The Human Resources Director will advise the patient that a grievance may be filed directly with the Bureau of Facility Standards at 450 W. State Street, Boise, Idaho 83720, (208) 334-8826, instead of using the CMC complaint/grievance process." This information provided to patients and staff was not accurate. The correct address of the Idaho Bureau of Facility Standards is 3232 Elder St, Boise ID, 83720. Additionally, the correct phone number for the Idaho Bureau of Facility Standards is (208) 334-6626.

The CAH's grievance policy stated, "During admission, all patients will receive a copy [sic] Patient Bill of Rights, which notifies them of their rights as a patient of CMC." This "PATIENT BILL OF RIGHTS," which was provided directly to patients as well as posted in the CAH's lobby, included an incorrect Idaho Bureau of Facility Standards address for the purpose of filing a grievance. Additionally, the document did not include a telephone number for the Idaho Bureau of Facility Standards, in the event a patient or representative wished to verbalize a grievance. It could not be determined how patients and their representatives could file a grievance with the SA with incorrect information provided by the CAH.

The CNO was interviewed on 11/18/20, beginning at 10:33 AM, and the CAH's grievance policy and patient rights information was reviewed in her presence. She confirmed the address and phone number of the SA provided to patients and their representatives was not accurate and the policy was not appropriately written.

The CAH's grievance policy was not appropriately written.

b. A CAH policy, "DISCHARGE of the Patient," dated May 2014, stated, "Use ExitCare within Healthland to obtain discharge instructions...Document within Healthland using a discharge assessment."

At the time of survey, the CAH utilized an EMR system named "Athena." It was unclear what "ExitCare" or "Healthland" was.

The CNO was interviewed on 11/18/20, beginning at 10:33 AM, and the CAH's discharge policy was reviewed in her presence. She stated the CAH had not used the EMR system "Healthland" in over 2 years. The CNO confirmed the CAH's discharge policy was not appropriately written.

The CAH's discharge policy was not appropriately written.

c. A CAH policy, "Inpatient/ Outpatient/ Swing-Bed Patient," revised May 2014, stated, "Nursing care will be documented in Healthland per facility protocol...ExitCare discharge instructions will be given to all patients."

At the time of survey, the CAH utilized an EMR system named "Athena." It was unclear what "ExitCare" or "Healthland" was.

The CNO was interviewed on 11/18/20, beginning at 10:33 AM, and the CAH's inpatient/outpatient/swing-bed policy was reviewed in her presence. She stated the CAH had not used the EMR system "Healthland" in over 2 years. The CNO confirmed the CAH's policy was not appropriately written.

The CAH's inpatient/outpatient/swing-bed policy was not appropriately written.

3. CAH staff provided services without a written policy.

Patient #19 was a 65 year old male admitted on 4/16/20 for a urinary tract infection. Patient #19's medical record documented he was managing and administering his home medications while a CAH inpatient. Examples include:

a. Patient #19's medical record included a Medication Administration Record, dated 4/17/20. The following medications for Patient #19 were not administered by an RN:

- Amlodipine, the documented reason: "pt took his own home med."

- Aspirin, the documented reason: "pt took his own home med."

- Atorvastatin, the documented reason: "pt took his own home med."

- Furosemide, the documented reason: "pt took his own home med."

- Hydrochlorothiazide, the documented reason: "pt took his own home med."

- Tresiba FlexTouch U-100 subqcutaneous Pen, the documented reason: "pt took his own home med."

b. Patient #19's medical record included a Nursing Note, dated 4/20/20, signed by an RN, which stated, "patient stated that he took his home medications."

c. Patient #19's medical record included a Medication Administration Record, dated 4/23/20. The ordered medication, tamsulosin, was not administered by an RN, the documented reason: "Patient is managing his own medication from home."

d. Patient #19's medical record included a Nursing Note, dated 4/23/20, signed by an RN, which stated, "pt has self administered his home meds..."

e. Patient #19's medical record included a Nursing Note, dated 4/24/20 at 8:00 AM, signed by an RN, which stated, "[Patient #19] is awake...he reports he was nauseated last night, and took 1 of his Zofran...he did not notify nursing staff." An RN narrative entry on the same day at 8:15 AM, stated, "[Patient #19] continues to manage his own home medications..."

The CNO was interviewed on 11/19/20, beginning at 10:40 AM, and Patient #19's medical record was reviewed in her presence. The CNO confirmed the CAH did not have a policy for patients to manage/administer their medications while admitted as an inpatient, and the expectation was for RN staff to manage/administer medications.

CAH staff provided services without a written policy.

Based on observation, staff interview, and review of facility policy and procedures, it was determined that the CAH failed to ensure policies failed to govern the rules for storage of drugs and biologicals. This had the potential for adverse medication reactions. Findings include:

1. On 11/19/20 starting at 8:50 AM, a tour of the Radiology Department was conducted in the presence of the Radiology Lab Manager. The department stored medications used for IV contrast. "ISOVUE-300 Iopamidol Injection 61%" and "ISOVUE-370 Iopamidol Injection 76%" IV contrast, administered to patients prior to a CT scan, were stored in a cupboard, and placed in a warming unit prior to administration.

a. Manufacturer's IFU for the storage of the IV contrast medication states the medication should, "be stored at 20-25° C (68-77° F)."

b. Manufacturer's IFU for the warming of the IV contrast stated, "It is desirable that solutions of radiopaque diagnostic agents for intravascular use be at body temperature when injected."

The Radiology Lab Manager was interviewed during the tour, beginning at 8:50 AM. He stated there were no policies or procedures for monitoring the storage and warming temperatures of the IV contrast. The Radiology Lab Manager the cupboard and warming unit were not monitored for temperatures.

The CAH failed to ensure policies governed the rules for the storage of IV contrast.

2. On 11/18/20 starting at 8:50 AM, a tour of the pharmacy, medication room, and nurses' station was conducted in the presence of the CNO. The medication preparation area contained a medication refrigerator for patient use.

The temperature log for medication refrigerator was requested and a copy of the "CMC RN SHIFT CHECK LIST" was provided. One of the required items on the check list for day-shift nursing staff was, "Check and record medication room refrigerator temps." The dates of 4/01/20 to 9/12/20, a total of 165 days, was reviewed. There were no recorded entries for 65 out of 165 days reviewed, a 39% fail rate.

It could not be determined if the CAH monitored stored patient medication temperatures daily.

The CNO was interviewed during the tour, beginning at 8:50 AM. She confirmed there was no policy for medication refrigerator temperature monitoring, but the expectation was for a day-shift RN to perform this duty.

The CAH failed to ensure policies governed rules for storage of refrigerated medications.

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to ensure nursing services met the needs of 4 of 20 inpatients (Patients #1, #2, #9, and #19) whose records were reviewed. This resulted in wounds not being assessed and documented, care plans not updated, orders not being followed, and the patient's care needs not being met. Findings include:

1. Patient #11 was a 69 year old male admitted on 3/22/20 for hypoxia.

a. Patient #11's medical record included an Admission Assessment & Plan, dated 3/22/20, signed by an NP, which stated, "Patient reports 30 hours with difficulty managing his secretions..."

b. Patient #11's medical record included a Respiratory Order, dated 3/22/20, signed by an NP, which stated, "Incentive spirometry every hour while patient is awake now." The Mayo clinic website, accessed on 11/25/20, reports "Performing deep-breathing exercises (incentive spirometry) and using a device to assist with deep coughing may help remove secretions and increase lung volume."

Patient #11's medical record did not include a nursing care plan for administering or assisting him with incentive spirometry every hour while he was awake.

The CNO was interviewed on 11/19/20, beginning at 10:40 AM, and Patient #11's medical record was reviewed in her presence. The CNO confirmed nursing services did not meet Patient #11's needs.

Nursing services did not meet Patient #11's respiratory needs.

2. Nursing services did not meet patients' wound care needs.

A CAH policy, "WOUND CARE," dated 7/13, instructs nursing to assess:

- "Age of wound (hours and days)..."

- "Size of wound; length, width, depth..."

- "Describe type of wound..."

- "Neurovascular status...Describe level of circulation and sensation distal to injury..." This policy was not followed. Examples include:

a. Patient #19 was a 65 year old male admitted on 4/16/20 for a urinary tract infection.

i. Patient #19's medical record included a Nursing Assessment, dated 4/16/20, signed by an RN, which stated, "[Patient #19] has limited mobility due to history of multiple sclerosis" and "posterior assessment not completed."

ii. Patient #19's medical record included a Nursing Assessment, dated 4/17/20, signed by an RN. The assessment included documentation of a Braden score of "15-18 Mild Risk [for development of pressure ulcers]."

iii. Patient #19's medical record included a Shift Assessment, dated 4/20/20, signed by an RN, which stated, "Integumentary breakdown: (left heel erythema, non-blanching. Breakdown on his toes from his fall on Thursday)."

iv. Patient #19's medical record included a Nursing Note, dated 4/23/20, signed by an RN, which stated, "He does have a non-blanching spot on his coccyx approximately 7 cm..."

v. Patient #19's medical record included a Progress Note, dated 5/18/20, signed by the MD, which stated, "healing first stage ulcer in the crease of the buttocks."

Patient #19's medical record did not include a nursing care plan to prevent skin breakdown and his wounds were not documented per CAH policy.

The CNO was interviewed on 11/19/20, beginning at 10:40 AM, and Patient #19's medical record was reviewed in her presence. The CNO confirmed that CAH wound care policy was not followed and that the expectation was for a nursing care plan to include interventions to prevent skin breakdown, wound care orders for current wounds, and for RNs to create wound flowsheets in the EMR to consistently assess and monitor wounds for all patients with skin integrity issues and that have current wounds. She confirmed Patient #19 did not have wound care orders or nursing interventions. The CNO confirmed nursing services did not meet Patient #19's needs.

Nursing services did not meet Patient #19's wound care needs.

b. Patient #1 was a 37 year old male admitted 1/06/20 for diabetic foot ulcers, cellulitis, and DM type I. His medical record documented he was a, "Type I diabetic, uncontrolled," and a history of a toe amputation.

Patient #1's medical included potential wounds as follows:

i. Patient #1's medical record included a Nursing Admission Note, dated 1/06/20, signed by an RN, which stated, "Events leading to hospitalization: [Patient #1] has had a developing ulcer on his right foot, second toe, dorsal side. He went to the clinic today, and was diagnosed with cellulitis and admitted for inpatient treatment of his infection and wound care."

ii. Patient #1's medical record included a Nursing Assessment, dated 1/06/20, signed by an RN, which stated, "Integumentary no bruising; skin appropriate color for race; skin warm and dry; wound: (right big toe, foot edema)." The nursing assessment had an addendum signed by the same RN, which stated, "Correction, wound is on right 2nd, 3rd toes."

iii. Patient #1's medical record included a Progress Note dated 1/07/20, signed by an NP, which stated, "Skin: Inspection and palpation...ulcer (at top of right 2/3 toes...)"

iv. Patient #1's medical record included a Assessment & Plan, dated 1/07/20, signed by an NP, which stated, "Diabetic foot ulcers, cellulitis - IV ertapenem vancomycin...)"

The CNO was interviewed on 11/19/20, beginning at 10:40 AM, and Patient #1's medical record was reviewed in her presence. The CNO confirmed CAH wound care policy was not followed and that the expectation was for a nursing care plan to include wound care orders for current wounds, and for RNs to create wound flowsheets in the EMR to consistently assess and monitor wounds for all patients with skin integrity issues and that have current wounds. She confirmed Patient #1 did not have wound care orders or nursing interventions for wound care. The CNO confirmed nursing services did not meet Patient #1's needs.

Nursing services did not meet Patient #1's wound care needs.

c. Patient #2 was a 83 year old male admitted on 1/23/20 for congestive heart failure.

i. Patient #2's medical record included an assessment and plan as part of the Admission H&P, dated 1/23/20, signed by the MD, which stated, "Lower extremity edema with blisters and wounds...sequential wrapping and Ace wraps did improve the lower extremity swelling...I think that is our best bet for the moment to continue improved circulation and also wound healing. Pictures were taken..." The H&P also stated, "edema has been worsening about 2 to 3 days ago the skin was so tight that skin started to blister and open up...despite diuretic therapy he will need to continue sequential compression therapy and daily compression therapy..."

ii. Patient #2's medical record included a Nursing Note, dated 1/22/20, signed by a RN which stated, "bandages are intact and dry at this time."

iii. Patient #2's medical record included a Nursing Note, dated 1/23/20, signed by an RN, which stated, "Wounds were dressed with mupirocin ointment, Adaptic, followed by a Telfa pad, and gently wrapped with Kerlix. The feet and legs, were then wrapped with Ace bandages..."

iv. Patient #2's medical record included a Nursing Note, dated 1/24/20, signed by an RN, which stated, "Removed SCD's from bilat legs...Re-wrapped bilat legs with ace bandage over kerlex [sic] that is still on bilat legs."

v. Patient #2's medical record included a Discharge Summary, dated 1/25/20, signed by an MD, which stated, "Patient came to ER. Labs were done. Compression was applied to his legs. Basic wound care was done to the wounds on his legs." An addendum dated 2/05/20, signed by the MD, stated, "Patient was admitted after coming to the clinic, and we discovered his significant edema and new wounds. Patient was admitted...compression socks were applied...edema and wound wraps were applied..."

The CNO was interviewed on 11/19/20, beginning at 10:40 AM, and Patient #2's medical record was reviewed in her presence. The CNO confirmed that CAH wound care policy was not followed and that the expectation was for a nursing care plan to include wound care orders for current wounds, and for RNs to create wound flowsheets in the EMR to consistently assess and monitor wounds for all patients with skin integrity issues and that have current wounds. She confirmed Patient #2 did not have wound care orders, wound care flowsheets and nursing interventions for wound care. The CNO confirmed nursing services did not meet Patient #2's needs.

Nursing services did not meet Patient #2's wound care needs.

Based on medical record review and staff interview, it was determined the CAH failed to ensure all medications were administered by an RN or under the supervision of an RN for 1 of 20 inpatients (Patient #19), whose records were reviewed. This had the potential for patient safety issues and unmet medication needs. Findings include:

Patient #19 was a 65 year old male admitted on 4/16/20 for a urinary tract infection. Patient #19's medical record documented he was managing and administering his home medications while an inpatient at the CAH. Examples include:

Patient #19's medical record included a Medication Administration Record for 4/17/20. The following medications were not administered by an RN:

- Amlodipine, the documented reason: "pt took his own home med."

- Aspirin, the documented reason: "pt took his own home med."

- Atorvastatin, the documented reason: "pt took his own home med."

- Furosemide, the documented reason: "pt took his own home med."

- Hydrochlorothiazide, the documented reason: "pt took his own home med."

- Tresiba FlexTouch U-100 subqcutaneous Pen, the documented reason: "pt took his own home med."

1. Patient #19's medical record included a Nursing Note, dated 4/20/20, signed by an RN, which stated, "patient stated that he took his home medications."

2. Patient #19's medical record included a Medication Administration Record, dated 4/23/20. The ordered medication, tamsulosin, was not administered by an RN, the documented reason: "Patient is managing his own medication from home."

3. Patient #19's medical record included a Nursing Note, dated 4/23/20, signed by an RN, which stated, "pt has self administered his home meds..."

4. Patient #19's medical record included a Nursing Note, dated 4/24/20 at 8:00 AM, signed by an RN, which stated, "[patient] is awake...he reports he was nauseated last night, and took 1 of his Zofran...he did not notify nursing staff." An RN narrative entry on the same day at 8:15 AM, stated, "[Patient #19] continues to manage his own home medications..."

The CNO was interviewed on 11/19/20, beginning at 10:40 AM, and Patient #19's medical record was reviewed in her presence. The CNO confirmed the CAH did not have a policy for patients to manage/administer their medications while admitted as an inpatient, and the expectation was for RN staff to manage/administer medications.

CAH failed to ensure Patient #19's medications were administered by an RN or under the supervision of an RN.

Based on observation, policy review, document review, and staff interview, it was determined the CAH failed to ensure visitation rights were provided to each patient or his/her representative for 34 of 34 patients (Patient #'s 1 -34) whose records were reviewed. This had the potential to interfere with the patients' choice to receive or not receive specified visitors, as well as patient understanding of the facility's possible need to restrict visitation during an active COVID-19 pandemic. Findings include:

A CAH policy, "Patient Rights," revised January 2011, was reviewed. The policy listed 14 separate patient rights for ED patients and inpatients, but focused heavily on patient rights regarding swing-bed patients. The 14 patient rights did not include visitation rights.

A CAH policy, "VISITORS in The EMERGENCY DEPARTMENT (ED)," undated, was reviewed. The policy documented encouragement of visitors to patients in the ED specifically. The policy did not refer to inpatient or swing-bed patients. Additionally, the policy did not describe how patients and their representatives were informed of their visitation rights, whether they be written, verbal, or both.

The CAH lobby was observed in the presence of the CNO on 11/18/20, beginning at 11:42 AM. A CAH document, "PATIENT BILL OF RIGHTS," posted in the lobby, was reviewed. The document included 11 separate patient rights for all patients of the CAH, however, it did not include visitation rights. It could not be determined how patients and their representatives were informed for their visitation rights, whether they be written, verbal, or both.

Patient #'s 1 - 34's medical records were reviewed. The medical records did not include written or verbal notification of visitation rights information. It could not be determined how patients and their representatives were informed for their visitation rights, whether they be written, verbal, or both.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and the above patient's medical records and policies were reviewed in her presence. She stated visitation rights were provided to patients and their representatives verbally, but confirmed this was not documented in policy or in medical records. The CNO confirmed CAH policies and patient rights information was not complete.

The CAH failed to document how it provided patient visitation rights to patients and their representatives.

Based on observation, medical record review, and staff interview, it was determined the CAH failed to ensure clinical records were complete, accurate, and safeguarded from loss. This resulted in incomplete, inaccurate medical records and had the potential for confusion as to the course of patient care. Findings include:

1. Refer to C-1104, as it relates to the failure of the CAH to ensure inpatient medical records were complete.

2. Refer to C-1110, as it relates to the failure of the CAH to ensure informed consents were executed properly.

3. Refer to C-1120, as it relates to the failure of the CAH to ensure medical record information was safeguarded against destruction by water damage.

The cumulative effect of these systemic practices impeded the ability of the CAH to maintain a quality and accessible medical record system.

Based on medical record review and staff interview, it was determined the CAH failed to ensure inpatient medical records were complete for 1 of 20 inpatients (#'s 1 - 20), whose records were reviewed. This resulted in a lack of documented discharge planning and had the potential to delay and fragment patient care for all patients admitted to the CAH. Findings include:

Twenty inpatient records for Patient #'s 1 - 20 were reviewed and did not include discharge planning. It could not be determined what discharge planning was created and executed for inpatients prior to them leaving the CAH. Patient #'s 1 - 20's medical records did not include:

- Documented discharge planning

- Identified patient goals

- Identified patient treatment preferences

- Documented family members/caregivers/support persons as active partners in the discharge planning process

The CNO was interviewed on 11/20/20, beginning at 8:20 AM, and the above patients' medical records were reviewed in her presence. She stated the CAH's current EMR system did not have the ability to create patient discharge planning. The CNO stated the CAH's EMR vendor informed them they would not be doing a system upgrade to include discharge planning. She stated staff did not document discharge planning outside the purview of the CAH's EMR system, such as paper charting.

The CAH failed to ensure inpatient medical records were complete.

Based on medical record review and staff interview, it was determined the CAH failed to ensure informed consents were executed properly for 11 of 34 patients (#2, #7, #12, #13, #15, #16, #19, #20, #23, #25, and #32), whose records were reviewed. This had the potential for misunderstanding of the course of patient care and the ability for patients and their representatives to exercise their patient rights. Examples include:

1. Patient initial treatment informed consents were not properly executed. Examples include:

a. Patient #12 was a 68 year old male who was admitted to the CAH on 4/23/20, with a primary diagnosis of a concussion.

Patient #12's medical record included an initial patient treatment consent which was signed by him, but not dated. It could not be determined if the consent was executed prior to or after initial patient treatment.

b. Patient #15 was a 31 year old male who was admitted to the CAH on 6/28/20, with a primary diagnosis of an abscess.

Patient #15's medical record included an initial patient treatment consent which was signed by him, but not dated. It could not be determined if the consent was executed prior to or after initial patient treatment.

c. Patient #16 was an 88 year old female who was admitted to the CAH on 10/12/20, with a primary diagnosis of ARF.

Patient #16's medical record included an initial patient treatment consent which was signed by him, but not dated. It could not be determined if the consent was executed prior to or after initial patient treatment.

d. Patient #2 was an 83 year old male admitted on 1/23/20 with a primary diagnosis of congestive heart failure.

Patient #2's medical record included an initial patient treatment consent which was signed by him, but not dated. It could not be determined if the consent was executed prior to or after initial patient treatment.

e. Patient #7 was an 86 year old male who was admitted to the CAH on 2/28/20 with a primary diagnosis of congestive heart failure.

Patient #7's medical record included an initial patient treatment consent which was signed by him, but not dated. It could not be determined if the consent was executed prior to or after initial patient treatment.

f. Patient #20 was a 52 year old male who was admitted to the hospital on 9/01/20, with a primary diagnosis of weakness and ETOH withdrawal.

Patient #20's medical record included an initial patient treatment consent, dated 9/01/20, but signed as "verbal." It was unclear what "verbal" meant, as there was no follow-up to the signature and/or clarification.

g. Patient #23 was a 41 year old male who was seen in the CAH's ED on 11/13/20, with a presenting diagnosis of suicidal ideation.

Patient #23's medical record included an initial patient treatment consent, dated 11/13/20, but signed as "verbal." It was unclear what "verbal" meant, as there was no follow-up to the signature and/or clarification.

h. Patient #25 was a 63 year old female who was seen in the CAH's ED on 9/28/20, with a presenting diagnosis of ETOH intoxication.

Patient #25's medical record included an initial patient treatment consent, dated 9/28/20, but signed as "verbal." It was unclear what "verbal" meant, as there was no follow-up to the signature and/or clarification.

i. Patient #13 was a 68 year old female who was admitted to the hospital on 4/27/20, with a primary diagnosis of dyspnea and pleural effusion.

Patient #13's medical record included an initial patient treatment consent and privacy form, dated 4/27/20, but signed as "verbal." It was unclear what "verbal" meant, as there was no follow-up to the signature and/or clarification.

j. Patient #19 was a 65 year old male who was admitted to the hospital on 4/16/20, with a primary diagnosis of a urinary tract infection.

Patient #19's medical record included an initial patient treatment consent and privacy form, dated 4/17/20, but signed as "verbal." It was unclear what "verbal" meant, as there was no follow-up to the signature and/or clarification.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and the above medical records were reviewed in her presence. She confirmed the initial treatment consents were not properly executed.

Initial patient treatment informed consents were not properly executed.

2. Patient blood administration informed consents were not properly executed. An example includes:

Patient #32 was a 42 year old female who was seen in the CAH's ED on 5/28/20, with a primary diagnosis of hemorrhage.

Patient #32's medical record included a "BLOOD SIGN-OUT SHEET," dated 5/28/20, signed by her physician, which documented she received 1 unit of blood. However, her medical record did not include a blood administration informed consent.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and Patient #32's medial record was reviewed in her presence. She confirmed Patient #32's medical record did not include a blood administration informed consent.

Patient #32's blood administration informed consent was not properly executed.

Based on observation and staff interview, it was determined the CAH failed to ensure medical records were safeguarded against destruction by water damage for 2 of 2 medical record storage areas observed. This had the potential for inaccessible medical records. Findings include:

A tour of the CAH was conducted on 11/16/20, beginning at 2:25 PM, in the presence of the CNO. A room located in the CAH basement and a storage room on the main level were utilized for storage of original, non-archived patient medical records. The medical records were uncovered and arranged in folders. Fire sprinklers were noted in these areas 2 areas to protect the medical records from fire damage, however there was no countermeasure in place to protect the medical records from water damage.

The CNO was interviewed on 11/19/20, beginning at 10:40 AM. When asked if the medical records in the CAH basement room and hallway storage room were original, non-archived documents, the CNO stated yes. The CNO confirmed the medical records in these rooms were not safeguarded against destruction by water damage.

The CAH failed to ensure medical records were safeguarded against destruction by water damage.

Based on observation, policy review, document review, CDC infection control guidelines review, and staff interview, it was determined the CAH failed to maintain a functional and sanitary environment for patients. This had the potential to place all patients receiving care at the facility at an increased risk for infection. Findings include:

1. During a tour and interview with housekeeping services on 11/17/20, beginning at 1:30 AM, the Housekeeper stated she had not been trained to provide environmental and laundry services for a healthcare facility by the CAH. She stated her previous housekeeping experience had been at non-healthcare businesses. The housekeeper stated she was not aware of any housekeeping policy or procedures for her to follow and she did not document completed cleaning duties. The housekeeper was unaware of the CDC guidelines to use EPA registered cleaning agents specific to healthcare facilities and stated that she used the same cleaning agents from her previous, non-healthcare related employment.

The CDC website, accessed on 12/01/20, recommends disinfecting with a household cleaner that is listed on the EPA's: "List N: Disinfectants for use against SARs-CoV-2."

During an interview with the CNO on 11/17/20, beginning at 2:30 PM, she confirmed the CAH followed CDC guidelines for their environmental services. She confirmed the CAH had not trained the Housekeeper in procedures for keeping a healthcare facility sanitary. The CNO provided a manual for housekeeping policy and procedures, but confirmed they had not been reviewed for at least 10 years and did not follow current CDC guidelines. She confirmed two of the cleaning agents used by housekeeping were not EPA registered for healthcare facilities.

The CAH failed to train housekeeping staff to maintain a sanitary environment.

2. During a tour and interview with the CNO on 11/17/20, beginning at 2:30 PM, the nursing station and medication preparation room were examined. The CNO stated it was nursing responsibility to clean those areas and provided a CMC log, "CMC RN SHIFT CHECKLIST," to document the cleanings. The checklist included a line item task to "Disinfect Nurses station & Med Room with Disinfectant at end of shift." The CNO stated this duty was to be completed by day-shift and night-shift nursing staff. The checklist was reviewed in the presence of the CNO. The dates of 4/01/20 to 9/12/20 were reviewed for all shifts. There were no recorded entries for 168 shifts in the reviewed time frame, a 51% fail rate.

The CAH failed to ensure sanitary cleaning was documented.

3. A CAH policy, "Updated COVID Protocols: August 4, 2020," stated, "Universal mask requirement. All staff, patients, and visitors are to wear a face covering or mask when in the facility, leaving it on at all times when in the facility. Mask is to cover nose and mouth. Additionally, patients will be directed to practice hand hygiene upon entering facility." This policy was not followed.

On 11/17/20 at 2:53 PM, surveyors observed the ED admission of Patient #31. Patient #31 was escorted unmasked, and in the custody of 5 masked law enforcement personnel. Neither patient nor law enforcement personnel were screened for COVID-19 until after entering the CAH and were not instructed to hand sanitize. Patient #31 did not receive a mask until after entering the CAH. Patient #31's mask was ill fitting after placement and his nose was continually exposed.

During an interview with the CNO on 11/20/20, beginning at 8:20 AM, she confirmed staff had not followed policy and expectations for infection control during this encounter.

ED staff failed to follow CAH infection control policy.

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to have a discharge planning process for 20 of 20 inpatients (Patient #'s 1 - 20), whose records were reviewed. This resulted in undocumented discharge planning affecting all patients admitted to the CAH. Findings include:

A CAH policy, "DISCHARGE of the Patient," dated May 2014, stated, "Patient will have a Provider order and a discharge plan prior to discharge." This policy was not followed.

Twenty inpatient records for Patient #'s 1 - 20 were reviewed and did not include discharge plans. It could not be determined what discharge planning was created and executed for these patients prior to them leaving the CAH

The CNO was interviewed on 11/20/20, beginning at 8:20 AM, and the patients' medical records were reviewed in her presence. She stated the CAH's current EMR system did not have the ability to create patient discharge planning. The CNO stated the CAH's EMR vendor informed them they would not be doing a system upgrade to include discharge planning. She stated staff did not document discharge planning outside the CAH's EMR system, such as paper charting. The CNO confirmed CAH policy was not followed.

The CAH did not document discharge planning for inpatients.

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to document how it provided swing-bed patient rights to 3 of 3 swing-bed patients (#2, #18, and #20), whose records were reviewed. This had the potential for patients being unaware and unable to exercise their rights. Findings include:

A CAH policy, "Patient Rights," revised January 2011, was reviewed. The policy listed 14 separate patient rights for ED patients and inpatients, but it did not include how these rights were provided to patients and their representatives, whether that be verbally or written.

Patient #2, #18, and #20's medical record were reviewed and did not include notification of verbal or written swing-bed patient rights information. It could not be determined how swing-bed rights were provided to patients and their representatives, whether that be verbally or written.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and the above medical records were reviewed in her presence. She stated swing-bed patient rights were provided to swing-bed patients and their representatives verbally, but confirmed this was not documented in policy or in medical records. The CNO confirmed CAH policies and swing-bed patient rights information was not complete.

The CAH failed to document how it provided swing-bed patient rights to swing-bed patients and their representatives.

Based on medical record review, policy review, annual evaluation review, and staff interview, it was determined the CAH failed to provide and monitor medically-related social services to 1 of 3 swing-bed patients (Patient #20), whose records were reviewed. This resulted in a missed opportunity for psychosocial intervention of a potentially suicidal patient who signed himself out of the CAH AMA and had the potential to affect all patients who required social services at the CAH. Findings include:

1. The CAH failed to monitor social services provided to patients. Examples include:

a. The CAH's policy table of contents included 232 approved, active policies which ranged from acute care to billing practices. The CAH did not have social services policies to include their roles, responsibilities, services provided, scope and availability, and processes. It could not be determined how social services, especially for psychiatric, swing-bed, and difficult discharge planning patients, were integrated in to the CAH's patient care delivery system.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and the CAH's policy table of contents was reviewed in her presence. She confirmed the CAH did not have approved, active policies for social services. The CNO stated the sole social worker primarily worked in their affiliated RHC and would come to the CAH to provide services as needed. Additionally, the CNO stated the social worker would take part in the interdisciplinary committee for swing-bed patients, but confirmed this was not documented.

b. The CAH's most recent annual evaluation, dated 3/11/20, was reviewed. The evaluation did not include documented review of social services. It could not be determined how social services at the CAH was monitored and evaluated.

The CNO was interviewed on 11/18/20, beginning at 10:33 AM, and the CAH's annual evaluation was reviewed in her presence. She confirmed social services was not currently part of the CAH's program evaluation.

The CAH failed to ensure its quality assurance program evaluated social services.

2. The CAH failed to ensure social services were provided. An example includes:

Patient #20 was a 52 year old male who was admitted on 9/01/20, with a primary diagnosis of right sided weakness and history of ETOH abuse. He was first admitted to observation and then swing bed status on 9/03/20. Patient #20 left the hospital AMA on 9/03/20.

Patient #20's medical record included an ED patient assessment, dated 9/01/20, signed by a PA, which stated, "He is known to have 2 - 3 people who live with him and are present to provide care - however [Patient #20] was found with a bucket tied to him for [sic] assist with his bowels the first time EMS responded last night. The second time EMS responded, he was on a frying pan used as a bedpan and was covered in feces, urine."

Patient #20's medical record included a progress note, dated 9/02/20, signed by a PA, which stated, "[Patient #20] does have a roommate, but admits to very little help at home and wonders whether he is safe there."

Patient #20's medical record included a physician progress note, dated 9/03/20, signed by his attending physician, which stated, "suicidal risk...Also sees a therapist as far as depression and suicidal thoughts he has had in the past. It should be noted that he failed this suicide evaluation screen here in the hospital and does have a personal care attendant. Today is Saturday. Will have him seen by social worker on Monday to reassess the status. Hopefully, he can come off any sort of personal care tended [sic] need...Will ask Social Services to be involved as far as alcoholism and suicide risk...Regardless, we will ask for social services to evaluate this situation...Will ask Social Services to be involved as far as alcoholism and suicide risk...Total encounter time today was 65 minutes including outside record review and discussion with nursing staff related to suicidal risk concerns."

Patient #20's medical record included a physician progress note, dated 9/03/20, signed by his attending physician, which stated, "Continue swing bed care, but will seek to arrange further care at [SNF name] due to the fact that we don't have OT and inpatient social services here, and are limited on staffing."

Patient #20's medical record included a nursing note, dated 9/03/20, signed by an RN, which stated, "Pt discharged. Myself, another RN, and the Pts roommate attempted to convince the Pt that staying the night and continuing to search for a rehab to transfer him to in the AM would be a better plan. Pt refused. While going over DC paperwork Pt was upset, stated that he witnessed 'bad things' going on in the hospital. Stated that someone came into his room and "drug a needle across his forehead." Assume that a staff member was taking his temporal temperature. Also stated that he 'saw 3 kids, not wearing masks, brake [sic] into the closet across the hallway, and steel [sic] some coats.' Pt seemed confused about what was going on during the day. Stated that he thought 'we were going to kill him and blame it on COVID.' Stated that he 'did not feel safe' here. Pt required 2 staff members for transfer to the wheelchair, very weak. Also required 2 staff to help Pt into his roommates [sic] car."

Patient #20's medical record included "Discharge Instructions," dated 9/03/20, which stated, "Condition: Weak. Discharging against advice."

Patient #20's medical record did not include a CAH AMA form. It is unclear if Patient #20 signed himself out AMA, if he was competent to do so, or who informed him of the risks for leaving AMA.

CAH medical staff did not document if they notified law enforcement per policy or APS per Idaho statute regarding Patient #20.

The CNO was interviewed on 11/19/20, beginning at 1:26 PM, and Patient #20's medical record was reviewed in her presence. She stated she did not know why Patient #20's physician documented social services were not available at the CAH. The CNO stated the social worker was available after hours and on weekends to meet patient needs.

Patient #20's swing-bed physician, who was also the CAH's Medical Director, was interviewed on 11/19/20, beginning at 2:57 PM, and Patient #20's medical record was reviewed in his presence. He stated he called the CAH's social worker on 9/03/20 regarding Patient #20, but did not receive a call back. The Medical Director confirmed this was not documented.

The CAH failed to ensure social services were provided to Patient #20.