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Based on staff interview and review of policies, it was determined the CAH failed to ensure pharmacy services were furnished in accordance with applicable state regulations and CAH policies. This resulted in an increased likelihood of medication errors. Findings include:

IDAPA "Rules & Minimum Standards for Hospitals in Idaho," part 16.03.14.330.06(a), states "The pharmacist shall review the prescriber's original order or a direct copy thereof" in relation to medication orders. This is an accepted professional principle of hospital pharmacy practice in Idaho that has been in place since 10/14/1988, when the rule was adopted.

A CAH policy titled "Pharmacy Order Verification," dated 12/04/17, stated a pharmacist would review all medication orders prior to administration of the first dose. The policy further stated "a direct copy of the order shall be provided to Pharmacy Services staff immediately after being written, or Pharmacy Services staff will be notified after direct CPOE (Computerized Physician Order Entry)."

The pharmacist was interviewed on 1/10/18, beginning at 8:00 AM. He stated when a medication order was written for inpatients, it was typically hand written on paper. He stated the nurse then transcribed the orders and entered them into the EMR. The pharmacist stated the nurse then notified him of the new orders and he went into the EMR and reviewed what the nurse had entered. He then updated the medication profile and supplied the medications. He stated he did not review a direct copy of medication orders.

The CAH failed to implement a system to review original medication orders or direct copies of those orders, as required by state licensure rules and the CAH's policy. This prevented the pharmacist from identifying transcription errors by nursing staff.

Based on observation, staff interview, and review of policies and scholarly articles, it was determined the CAH failed to ensure
a system for hand washing for the prevention of communicable diseases of patients, the public, and personnel was developed. This resulted in the inability of the CAH to provide a sanitary environment. Findings include:

Routine hand hygiene, including hand washing with soap and water after using the toilet, is universally recommended to reduce the incidence of infection.

An article published by the National Institutes of Health, dated 5/16/16, titled "Impact of sink location on hand hygiene compliance after care of patients with Clostridium difficile infection: a cross-sectional study," stated "Poor access to sinks is associated with decreased hand washing compliance."

A public restroom across from room 29 was observed by the surveyor and the IC Officer on 1/11/18, beginning at 9:00 AM. The room contained a toilet but it did not contain a sink. In addition, a shower room used for patients at the east end of the hallway contained a toilet but it did not contain a sink. The IC Officer confirmed the lack of a sink in the above areas. She stated the public restroom across from room 29 was the only restroom big enough to accommodate persons in wheelchairs. She stated the CAH's IC program did not include a plan to provide access to hand washing facilities for persons using these toilets.

The CAH failed to provide access to hand washing facilities for persons using the toilet.

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to ensure informed consents were properly executed for 3 of 5 patients (Patients #6, #7, and #8) whose acute admission records were reviewed. This resulted in a lack of patient consent for medical treatment, prior to treatment. Findings include:

1. A policy titled "Blood/Components Transfusion Consent", dated 3/21/12 and updated 2/01/17, stated "It is the policy of Power County Hospital to verify, by means of the Blood/Blood Component Transfusion Consent Form, that the patient's informed consent has been obtained by the treating physician/provider, before the patient receives a transfusion ..."

Patient #8 was an 84 year old female admitted to the facility on 1/05/17 with diagnoses including acute GI bleeding and anemia due to blood loss.

Patient #8 received three units of packed red blood cells on 1/05/17, and two units on 1/07/17. However, review of her medical record showed no consent to receive blood had been signed by the patient.

In an interview on 1/11/18 at 9:00 AM, the DON confirmed Patient #8 had not signed a consent form prior to receiving transfusion of five units of packed red blood cells.

2. A policy addressing medical consent for medical treatment, for acute patient admissions, could not be provided by the facility.

The facility provided an admission packet used for all patients admitted to the CAH. The packet included a document titled "Admission Agreement." The Admission Agreement included Medical Consent for treatment to be signed by the patient or their representative.

a. Patient #7 was a 64 year old female admitted to the facility on 5/23/17 with diagnoses including acute encephalopathy and acute kidney failure. She was assessed in the ED, started on IV antibiotics, and lab work was drawn. She was then admitted to a room on the acute care floor.

Patient #7's medical record included an Admission Agreement, dated 5/24/17 at 11:31 AM. The document was not signed by the patient or her representative.

In an interview on 1/11/18 at 9:00 AM, the DON and the Director of Medical Records confirmed Patient #7 did not have a signed Consent for Medical Treatment.



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b. Patient # 6 was a 35 year old male admitted to the facility on 2/06/17, with a diagnosis of DKA, acute kidney injury, and hyperkalemia.

Patient #6's medical record did not include an Admission Agreement.

The Medical Records Scanner was interviewed on 1/11/18 at 10:45 AM. She confirmed that the Admission Agreement document was not included in the patients record.

The CAH failed to ensure consents were properly executed.

Based on observation and staff interview, it was determined the CAH failed to ensure medical record information was safeguarded against destruction by water damage in their medical record storage area. This had the potential to result in water damage of original medical records. Findings include:

A tour of the CAH's onsite medical record storage area was conducted on 1/10/18, beginning at 10:00 AM, in the presence of the DON. During the tour, multiple original, non-archived CAH medical records were organized in folders which were placed on open shelves. The medical records in the room were protected from fire damage due to the overhead sprinkler system. However, the exposed medical records were not safeguarded from potential water damage.

The Medical Records Supervisor was interviewed on 1/10/18, beginning at 10:00 AM. She confirmed the original, non-archived medical records were not safeguarded from potential water damage.

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

Based on record review and staff interview it was determined the facility failed to ensure 5 of 5 patients (Patient #1, #2, #3, #9, and #10) were guaranteed certain rights during their swing bed admissions. This failure created the potential for patients to have a less than dignified long term stay at the facility. Findings include:

In an interview on 1/10/18 at 10:00 AM, the charge nurse stated all patients, both acute status and swing bed status, admitted to the facility were provided with the same patient rights document. She provided a copy of the document.

Review of the Power County Hospital Patient Rights did not contain the following required swing bed patient rights:

- The right to be informed of charges
- The right to participate in care planning
- The right to refuse to perform services for the facility
- The right to send and promptly receive mail that is unopened
- The right to retain and use personal possessions, including furnishings and clothing
- The right to share a room with a spouse

In an interview on 1/11/18 at 9:00 AM, the DON confirmed the use of one patient rights document for all admissions to the facility. She said she was unaware the document did not contain all rights for swing bed patients.

The facility failed to ensure all swing bed patient rights were guaranteed.

Based on staff interview, policy review, and record review, it was determined the CAH failed to ensure comprehensive care plans were developed for 3 of 5 swing-bed patients (Patients #1, #2, and #3) whose closed records were reviewed. The lack of comprehensive care plans created the potential for inconsistent care and unmet needs. The findings include:

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

1. Patient #2 was a 66 year old male admitted to a facility swing bed after surgical repair of a fractured right femur.

Review of Patient #2's POC, from 9/08/17 - 10/06/17, showed no documentation that surgical wound assessment and monitoring was identified as a need for the patient. No nursing objectives, interventions, expected outcomes, or goals related to the patient's surgical wound were documented in the POC.

In an interview on 1/11/18 at 9:00 AM, the DON reviewed Patient #2's POC. She confirmed surgical wound care should have been addressed.

A comprehensive POC was not developed for Patient #2.



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2. Patient #1 was a 65 year old female admitted to the CAH's swing bed after acute treatment for pneumonia, respiratory failure, and a Clostridium difficile bowel infection. She was admitted on 6/10/17 and discharged on 6/20/17.

Patient #1's POC, initiated on 6/10/17, addressed 2 problems- "Imbalanced Nutrition: Less Than Body Requirements" and "Impaired Physical Mobility." Patient #1's POC did not address her respiratory problems or her bowel infection."

In an interview on 1/11/18 at 10:30 AM, the DON reviewed Patient #1's medical record. She stated the respiratory issues and bowel infection were not addressed in her POC.

The facility failed to ensure Patient #1's POC was comprehensive.

3. Patient #3 was a 95 year old female admitted to the CAH's swing bed after acute treatment for a subarachnoid hemorrhage and a cervical fracture. She was admitted on 1/07/17 and discharged on 2/09/17. Her discharge summary, dated 2/09/17, stated she suffered an episode of congestive heart failure on 1/20/17 which resulted in increased swelling and decreased blood oxygen levels.

Patient #3's medical record included a POC dated 1/19/17, 12 days after her start of care. Patient #3's POC addressed 1 problem, "Chronic Pain." Patient #3's POC did not address her subarachnoid hemorrhage, cervical fracture, or congestive heart failure.

In an interview on 1/11/18 at 10:30 AM, the DON reviewed Patient #3's medical record. She stated the subarachnoid hemorrhage, cervical fracture, and congestive heart failure were not addressed in her POC.

The facility failed to ensure Patient #3's POC was timely and comprehensive.

The facility failed to ensure comprehensive care plans were developed for all patients.