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229 SOUTH 7TH STREET

ST MARIES, ID 83861

No Description Available

Tag No.: C0154

Based on personnel record review, patient record review, and staff interviews, it was determined the facility failed to ensure that 1 of 2 full time contracted CRNAs (CRNA A) were fully credentialed before performing patient care and preceptor activities. This directly impacted 2 of 2 patients reviewed (#19 and #29) who received anesthesia during the survey (9/15/14-9/19/14). This resulted in services being provided by unqualified individuals and the potential for negative patient outcomes. Findings include:

Patient #19 was a 32 year old female admitted to the facility on 9/15/14 for obstetrical care and delivery of her infant. She had an epidural infusion for the management of pain during labor.

A consent for treatment, dated 9/15/14, and signed by Patient #19, included the following statement "..and that the treatment and procedures will be performed by physicians or hospital employees."

A consent for anesthesia services was signed by Patient #19 for a spinal or epidural on 9/15/14 at 8:10 AM. The consent for anesthesia included the statement "I hereby consent to the anesthesia service checked above and authorize that it be administered by [the names of CRNA A and the student] or his/her associates, all of whom are credentialed to provide anesthesia services at this facility."

Patient #29 was an 82 year old male admitted to the facility on 9/17/14 for a surgical repair of his left shoulder.

A consent for treatment, dated 9/17/14, and signed by Patient #29, included the following statement "..and that the treatment and procedures will be performed by physicians or hospital employees."

A consent for anesthesia services was signed by Patient #29 for a major nerve block and general anesthesia on 9/17/14 at 6:30 AM. The consent for anesthesia included the statement "I hereby consent to the anesthesia service checked above and authorize that it be administered by [the names of CRNA A and the student] or his/her associates, all of whom are credentialed to provide anesthesia services at this facility."

Credentials files were reviewed. There was no evidence the anethesia student was credentialled to provide anethesia at the facility or otherwise authorized by the state to provide services. CRNA A's credentials file was reviewed on 9/17/14. It was found he did not have a current Idaho Controlled Substance registration, and therefore, was not authorized to provide services in Idaho.

The Interim Administrator was interviewed on 9/17/14 beginning at 9:45 AM. He stated CRNA A did not have a current Idaho Controlled Substance registration. Additionally, he stated he was unaware of an agreement with the school the anesthesia student was from that outlined the scope of practice for the students.

The CAH failed to ensure practitioners providing services were qualified to do so.

No Description Available

Tag No.: C0204

Based on observations, review of crash cart checklists, and staff interviews, it was determined the hospital failed to ensure all emergency medical equipment was maintained for all patients receiving care at the facility. This resulted in the potential for patients' health and safety to be compromised in the event of a medical emergency. Findings include:

A tour of the facility's emergency room and medical/surgical floor was conducted on 9/16/14 starting at 8:30 AM. During the tour, the facility's emergency crash carts were observed. Each cart had a checklist that indicated the cart was to be checked daily at 9:00 AM and 9:00 PM. The crash cart checklists for the month of September 2014, were reviewed. Checks were not consistently completed as follows:

a. Emergency Room Trauma Room #1 crash cart:

There was no documentation the crash cart was checked on the following dates/times:

-9/05/14, No documentation of a 9:00 AM check.

-9/11/14, No documentation of a 9:00 PM check.

-9/12/14, No documentation of a 9:00 AM or 9:00 PM check.

-9/13/14, No documentation of a 9:00 AM check.

-9/17/14, No documentation of a 9:00 PM check.

-9/18/14, No documentation of a 9:00 PM check.

b. Emergency Room Trauma Room #2 crash cart:

-9/09/14, No documentation of a 9:00 PM check.

-9/05/14, No documentation of a 9:00 AM check.

-9/07/14, No documentation of a 9:00 AM or 9:00 PM check.

-9/10/14, No documentation of a 9:00 AM check.

-9/11/14, No documentation of a 9:00 PM check.

-9/12/14, No documentation of a 9:00 AM or 9:00 PM check.

-9/13/14, No documentation of a 9:00 AM check.

Staff ZZ, an emergency room RN, was interviewed on 9/16/14 at 8:45 AM. She stated emergency room crash carts are checked twice a day, at 9:00 AM and 9:00 PM, using the crash cart checklist. She confirmed staff on each shift did not consistently check off trauma rooms,1 and 2.

c. Medical/Surgical Floor crash cart:

The crash cart checklist did not include documentation of a 9:00 AM check on 9/02/14, 9/03/14, 9/06/14, 9/09/14, 9/10/14, 9/11/14, 9/12/14, 9/13/14, 9/17/14, and 9/18/14.

The Interim Administrator/DON was interviewed on 9/17/14 at 2:40 PM. He confirmed the medical/surgical floor crash cart had not been checked at 9:00 AM on the 10 dates above.

The facility failed to ensure emergency medical equipment was checked.

No Description Available

Tag No.: C0240

Based on staff interview, observation, and review of bylaws, credentials files, and CAH affiliation agreements, it was determined the CAH's organizational systems were not sufficient to ensure services were provided by qualified staff and all Conditions of Participation were met. This resulted in patients receiving services from unqualified and/or uncredentialled practitioners, the lack of an organized infection control program, lack of resolution of adverse event investigations, and lack of an operational system for organ, tissue, and eye procurement. Findings include:

1. Refer to C241 as it relates to the Governing Body's failure to ensure policies were implemented and monitored.

2. Refer to C270 Condition of Participation of Provision of Services and related standard level deficiences as they relate to the lack of an organized infection control program and lack of resolution of adverse event invesgitations.

3. Refer to C344 Condition of Participation of Organ, Tissue, Eye Procurement and related standard level deficiences as they relate to the lack of an operational system organ, tissue, and eye procurement.

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

No Description Available

Tag No.: C0241

Based on staff interview, observation, and review of bylaws, credentials files, and CAH affiliation agreements, it was determined the CAH's Governing Body failed to assume responsibility for implementing and monitoring compliance with policies. This directly impacted 2 of 2 sample patients (Patients #19 and #29 who received anethesia during the survey (9/15/14 - 9/19/14). The lack of oversight resulted in patients being treated by unqualified personnel. Findings include:

1. Article 1 of the Medical Staff Bylaws, dated 6/22/06, stated, "the purposes and responsibilities for the Medical Staff are to develop and implement, with the Board of Trustees approval, a written procedure for determining qualifications for Medical Staff appointment and for determining privileges."

Medical Staff Bylaws, Article 6, related to AHPs, stated "...they may be granted practice privileges if they hold a license, certificate or other credentials in a category of AHPs that the Board of Trustees, after consulting with the Medical Executive Committee, has identified as eligible to apply for practice privileges, and only if the AHPs are professionally competent and continuously meet the qualifications, standards and requirements set forth in the Bylaws and Rules."

Medical Staff Bylaws Article12.5.2 "Drug Enforcement Administration (DEA) Certificate" stated, "a. Revocation, Suspension and Expiration. Whenever a member's DEA certificate is revoked, limited, suspended or expired, the member shall automatically and correspondingly be divested of the right to prescribe medications covered by the certificate as of the date such action becomes effective and throughout its term."

CRNA A's credentials file was reviewed. It included a document, dated 8/11/14, written by the facility's Medical Staff Coordinator, and addressed to CRNA A. The document stated, "Our records indicate that the following documents have or will expire in the near future: "Proof of Liability Insurance (expires 8/20/2014), Controlled Substance License."

CRNA A's credentials file, also, included a document from the State of Utah Department of Commerce indicating CRNA A had an active license. Included in the document was "CRNA Controlled Substance Schedule 2-5, expiration 1/31/2014." Also, included was a DEA registration number, expiration date 7/31/15, with a state of Utah address.

An email in the CRNA A's credentials file, dated 9/03/14, from the DEA District Office in the State of Utah, to CRNA A, referenced unlawful activity and stated "Your DEA registration is a federal registration, but it is restricted to one physical address in one physical state of licensure. It is a violation of federal regulation to cross state lines with your DEA registration without first obtaining complete, valid state license in the state where you are moving to, and then you must absolutely have your DEA registration moved to the physical location in that state before you can begin practicing-period. The type of practice you perform is of no consequence. It does not alter the law."

In response to the above email, CRNA A forwarded the email to the Medical Staff Coordinator on 9/15/14. In the email CRNA A stated, "Waiting on Idaho Specialist as per email is out office till Sept 23."

The Interim Administrator was interviewed on 9/17/14 beginning at 9:45 AM. He stated, CRNA A did not have a current Idaho Controlled Substance registration, and had been practicing as a CRNA. He confirmed the facility had knowledge of the discrepancy prior to 9/17/14, and had not taken action. On 9/17/14 at approximately 1:15 PM, the Interim Administrator presented a letter to the CRNA A informing him his contract and privileges with the facility were suspended effective immediately. It was in regard to the email communication with CRNA A and the DEA.

The Governing Body did not enforce bylaws requiring a CRNA to have a current Controlled Substance registration.

2. During an observation of Patient #29's preparation for a surgical procedure on 9/17/14, beginning at 6:30 AM, a student nurse anesthetist conducted a nerve block in Patient #29's left shoulder. CRNA A was observed assisting the student. Patient #29 was transported to the operating room. The student nurse anesthetist administered sedating medications and placed a breathing tube to Patient #29. CRNA A observed the student.

CRNA A and a nurse anethetist student also provided services to Patient #19. Patient #19 was a 32 year old female admitted to the facility on 9/15/14 for obstetrical care and delivery of her infant. She had an epidural infusion for the management of pain during labor.

A consent for anesthesia services was signed by Patient #19 for a spinal or epidural on 9/15/14 at 8:10 AM. The consent for anesthesia included the statement "I hereby consent to the anesthesia service checked above and authorize that it be administered by [names of CRNA A and the student].."

An affiliation agreement, dated 7/13/13, between an out-of-state university anesthesia program and the CAH, for training registered nurse anesthetist students, was reviewed. Article III of the agreement, "RESPONSIBILITIES AND OBLIGATIONS OF THE CLINICAL SITE INSTITUTION", included "1. Conduct an orientation for each student with regard to the policies of the Clinical Site Institution and to provide each student a copy of the applicable policies and procedures. 2. Appoint a CRNA, who will be responsible for directing and coordinating Department students' experiences at the Clinical Site Institution. All supervision will be in accordance with Council on Accreditation policy and procedures."

A document in the CRNA A's credentials file titled, "DELINEATION OF PRIVILEGES", dated 12/24/13, was reviewed. It did not include privileges for supervising registered nurse anesthetist students.

The Medical Staff Bylaws, dated 6/22/06, stated at Article 6.3.2, "An AHP must apply and qualify for practice privileges as set forth in the Bylaws and Rules. Practitioners who desire to supervise or direct AHPs providing dependent services must apply and qualify for privileges to supervise approved AHPs."
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The Interim Administrator was interviewed on 9/18/14 beginning at 10:45 AM. He confirmed the facility's Bylaws and Rules did not address affiliation agreements with a certified nurse anesthetist university program. Additionally, he confirmed there were no guidelines for CRNA privileging, appointment or supervising roles of students. He also confirmed there was no formal orientation program or policies that governed certified nurse anesthetist students.

The Governing Body failed to grant specific privileges to CRNA A for supervising students and failed to ensure the scope of service provided by nurse anesthetist students was specified in writing.

No Description Available

Tag No.: C0270

Based on staff interview and review of medical records, adverse event logs, and CAH policies, it was determined the CAH failed to ensure 1) Policies and procedures were followed for the completion of investigations of adverse drug reactions, and errors in the administration of drugs. 2) Policies and procedures were implemented and followed for an active infection control program. These failures resulted in a lack of direction for staff, and had the potential to result in negative patient outcomes. Findings include:

1. Refer to C277 as it relates to the failure of the CAH to ensure policies and procedures for investigating adverse drug reactions and errors in the administration of drugs were followed.

2. Refer to C278 as it relates to the failure of the CAH to ensure an infection control plan was implemented to avoid the transmission of infections and communicable diseases.

The cumulative effect of these systemic omissions resulted in an increased risk of complications to patients.

No Description Available

Tag No.: C0277

Based on staff interview, and review of the hospital's incident log and policies, it was determined the CAH failed to ensure medication errors and adverse drug events had a final disposition or resolution. This failure had the potential to result in adverse patient outcomes. Findings include:

The "OCCURRENCE/EVENT NOTIFICATION MEDITECH RISK MANAGEMENT MODULE POLICY", dated 11/30/12 stated, "The hospital is committed to providing a safe environment for all patients, visitors, and employees within our facility. An event which occurs that is not consistent with the routine operations of a hospital or within the prescription and treatment of a particular patient will be documented so that appropriate response, follow-up, investigation, and resolution may be initiated and corrective action implemented, if necessary." Section, 4 e of the policy stated "Within 14 days of receipt of the original event notifications, the final disposition or resolution should be determined and documented within the event notification record."

The facility's "NOTIFICATIONS AND EVENTS REPORT", dated 7/01/13 through 9/15/14, were reviewed. Final disposition/resolution had not been determined and documented for the following events:

-12/23/13, wrong drug/solution
-12/24/13, wrong dose/rate
-12/28/13, wrong drug/solution
-04/14/14, wrong time/delayed
-04/22/14, wrong dose/rate
-04/28/14, wrong dose/rate
-05/03/14, medicine reconciliation incomplete
-05/27/14, wrong dose/rate
-07/06/14, wrong dose/rate
-08/08/14, adverse drug reaction
-08/09/14, adverse drug reaction

The Risk Manager was interviewed on 9/19/14 at 8:40 AM. She confirmed final resolution of the above events had not yet occurred.

The facility failed to ensure investigations of medication errors and adverse drug reactions were complete.

PATIENT CARE POLICIES

Tag No.: C0278

Based on staff interview and review of policies, it was determined the CAH failed to ensure systems to identify and investigate infections had been clearly defined and implemented. This resulted in the lack of direction to staff and the potential for patients to experience avoidable infections. Findings include:

The "INFECTION CONTROL PROGRAM POLICY" (DRAFT), unsigned, dated, 5/05/08, was reviewed. It did not include a plan for the CAH's IC program. Additionally, it did not specify a method for infection control surveillance and did not define nosocomial or hospital acquired infections.

The IC Officer was interviewed on 9/16/14 beginning at 1:50 PM. She stated the CAH administration did not formally designate her in writing nor did she have a job description. She stated the CAH did have an IC Committee and it was to meet quarterly. She confirmed the IC Committee had met only 2 quarters in 2014, on 2/06/14 and 4/22/14. She stated the Medical Staff reviewed IC data but did not provide policy direction for staff. She stated the IC Committee had not determined processes such as, procedures to clean surfaces and equipment or procedures to maintain a sanitary environment. She stated she tried to provide surveillance activities for the CAH, but an official procedure for surveillance of infections had not been approved. She further stated the hospital had not adopted an official definition of nosocomial (hospital acquired) infections.

The hospital failed to develop and implement a complete IC program.

No Description Available

Tag No.: C0302

Based on record review and staff interview it was determined the facility failed to ensure complete and accurate records were maintained for 2 of 6 surgical patients (#4 and #24) whose records were reviewed. This had the potential to interfere with coordination of patient care, result in misinterpretation of information, or cause a medical error. Findings include:

1. Patient #4 was a 73 year old female admitted on 9/4/2013 to Outpatient Surgery for an EGD ( a procedure used to visually examine your upper digestive system with a tiny camera) and Colonoscopy (a procedure in which a small camera is used to view the inner lining of the large intestine).

A form "Anesthesia Intra-Op Record" documented medications used during the procedure by CRNA B. The medication Propofol was circled but no dosage or amount was documented as given.

The same form contained an area for Post- Anesthesia Recovery discharge vital signs and boxes to indicate whether Patient #4 had been discharged home or moved to the hospital floor. The box "Home" was checked indicating she had been discharged home, but there were no vital signs documented to indicate she was stable for discharge. Further, there was no date or time to indicate when CRNA B had evaluated Patient #4 for discharge, as these lines were left blank.

During an interview on 9/18/2014 at 5:25 PM, CRNA B reviewed Patient #4's record. He confirmed the Propofol was given during the procedure. He also confirmed he had not documented how much was used. Further, CRNA B confirmed that no date, time, or vital signs had been documented in the Post-Anesthesia Recovery discharge section.

Patient #4's medical record was not complete or accurately documented.

2. Patient #24 was a 72 year old female admitted on 7/17/2014 to Outpatient Surgery for Right Total Knee Arthroplasty (a procedure which removes damaged cartilage and bone from the knee joint and replaces them with a man-made surface of metal and plastic).

Patient #24 received anesthesia for her procedure. Anesthesia was performed by a student nurse anesthetist during the procedure, which was indicated by the student's signature at the bottom of the "ANESTHESIA RECORD."

The same form contained a section "POST ANESTHESIA NOTE," which had checkboxes for "Patient without anesthesia complications or complaints," "See Progress Note," and "Outpatient." There were also lines for signature of the Anesthetist, date, and time. The entire section was left blank, with no markings in any of the boxes and no signature, date, or time.

During an interview on 9/18/2014 at 5:25 PM, CRNA B reviewed the record. He confirmed the section was blank and should have been filled out after recovery from anesthesia. CRNA B also confirmed he should have co-signed the form with the student nurse anesthetist.

Patient #24's medical record was not complete or accurately documented.

No Description Available

Tag No.: C0304

Based on staff interview, policy review, and record review it was determined the facility failed to ensure evidence of a properly executed informed consent for 1 of 6 surgical patients (#3) whose records were reviewed. This resulted in the potential for patients to not be fully informed about proposed anesthesia, surgical procedures, and the expected outcomes prior to the procedures. Findings include:

A policy "INFORMED CONSENT AND RIGHT OF REFUSAL" revised 11/30/2012, stated "Consents are required for any procedure of an invasive nature, involving anesthetic risk or a substantial element of risk or failure."

Patient #3 was a 32 year old male admitted to Outpatient Surgery on 7/25/14 at 9:30 PM, for an EGD (a procedure used to visually examine your upper digestive system with a tiny camera).

A form in Patient #3's record titled "Consent for Anesthesia Services" had a section at the bottom for the patient and witness to sign, date, and time receipt of the informed consent. Next to the patient signature the line for the required date and time was left blank. Also, next to the witness signature the line for the required date and time did not include a time.

During an interview with the DON on 9/19/2014 at 12:10 PM, the record was reviewed. He confirmed the consent for anesthesia did not have a date or time next to Patient #3's signature. He also confirmed there was no time next to the witness signature.

The facility failed to ensure Patient #3 had a properly executed informed consent.

No Description Available

Tag No.: C0308

Based on observatio and staff interview, it was determined the hospital failed to ensure patients' records were maintained confidential on the medical/surgical floor. This resulted in the potential for patients' telemetry information being viewed by unauthorized individuals. Findings include:

A tour of the facility's medical/surgical floor was completed on 9/18/14 beginning at 3:35 PM. The telemetry monitor (registers patients' heart rhythms) was located on the end of a counter, facing outward, behind the nursing station. The telemetry monitor was easily seen from the front of the nursing station, with patient names and their heart rhythms. The surveyor was able to observe the telemetry monitor for 10 minutes, while the nursing station was unattended.

Staff Z, an RN, was interviewed on 9/19/14 at 8:40 AM. She confirmed patient names and heart rhythms on the telemetry monitor could be in view of the public.

The facility failed to ensure patients' telemetry records were maintained confidential.

No Description Available

Tag No.: C0344

Based on staff interview and review of closed records, it was determined the facility failed to ensure written protocols were developed and implemented to address to organ, tissue and eye procurement. This had the potential to result in lack of identification of suitable organ, tissue and eye donors. Findings include:

1. Refer to C345 as it relates to the facility's failure to notify the OPO of individuals whose death is imminent or who have died in the facility.

2. Refer to C346 as it relates to the facility's failure to incorporate an agreement with at least one tissue bank and at least one eye bank to asssure that all usable tissues and eyes are obtained from potential donors.

3. Refer to C347 as it relates to the facility's failure to identify and obtain training for a designated requestor to approach potential donor families and request organ or tissue donation.

4. Refer to C349 as it relates to the facility's failure to work with the designated OPO, tissue bank and eye bank to educate staff on organ, tissue and eye donation issues.

The cumulative effect of this systemic practice created the potential for suitable organ, tissue and eye donors to not be identified.

No Description Available

Tag No.: C0345

33951

Based on review of closed records and staff interview, it was determined the facility failed to ensure the Organ Procurement Organization (OPO) was notified of the deaths of 3 of 6 patients (#8, #9 and #10), who expired in the facility and whose records were reviewed. This resulted in the potential for suitable organ, tissue and eye donors to not be identified. Findings include:

The "ORGAN AND TISSUE DONATION" policy and procedure, revised 11/19/2012 stated, "The procurement coordinator will be notified, in a timely manner, of all individuals whose death is imminent or who have died to determine eligibility for donation.

Under "PROCEDURE" the document stated, "Contact the procurement coordinator on-call to evaluate the patient's eligibility to donate. On the 'Donor Inquiry/Information to Funeral Home' form, document the Procurement Coordinators name, the case number, and whether or not the patient is a candidate."

This Policy and Procedure was not followed. Examples include:

1. Patient #8 was a 78 year old female admitted to the facility on 5/19/14, with diagnoses of sepsis and pneumonia. She expired on 5/23/14.

Patient #8's record did not include documentation of a call to the OPO, tissue or eye bank. Additionally, her record did not include the form titled, "Donor Inquiry/Information to Funeral Home".

During an interview on 9/18/14 at 4:10 PM, the Interim Administrator confirmed there was no documentation to indicate the OPO had been contacted prior to, or following, Patient #8's death.

The facility did not contact the OPO, tissue bank or eye bank at the time of Patient #8's death, to determine eligibility for organ and tissue donation.

2. Patient #9 was a 95 year old male admitted to the facility on 8/16/14, with a diagnosis of end stage COPD. He expired on 8/19/14.

Patient #9's record did not include documentation of a call to the OPO, tissue or eye bank. Additionally, his record did not include the form titled, "Donor Inquiry/Information to Funeral Home".

During an interview on 9/18/14 at 4:10 PM, the Interim Administrator confirmed there was no documentation to indicate the OPO had been contacted prior to, or following, Patient #9's death.

The facility did not contact the OPO, tissue bank or eye bank at the time of Patient #9's death, to determine eligibility for organ and tissue donation.

3. Patient #10 was an 83 year old male admitted to the facility on 8/28/14, with diagnoses of acute respiratory failure and lung cancer. He expired on 9/02/14.

Patient #10's record did not include documentation of a call to the OPO, tissue or eye bank. Additionally, his record did not include the form titled, "Donor Inquiry/Information to Funeral Home".

During an interview on 9/18/14 at 4:10 PM, the Interim Administrator confirmed there was no documentation to indicate the OPO had been contacted prior to, or following, Patient #10's death.

The facility did not contact the OPO, tissue bank or eye bank at the time of Patient #10's death, to determine eligibility for organ and tissue donation.

No Description Available

Tag No.: C0346

33951

Based on review of contracts and staff interview, it was determined the facility failed to incorporate an agreement with at least one tissue bank and at least one eye bank to coordinate retrieval of tissues and eyes from donors. This had the potential to result in failure of the facility to identify potential tissue and eye donors. Findings include:

A contract, titled "ORGAN RECOVERY AGREEMENT", dated 7/15/13, outlined an agreement between the facility and an OPO. Attached to the contract was a document with the OPO's letterhead, titled, "Commonly Asked Questions". The document included the question, "Does an agreement with (name of OPO) include the needed tissue and eye agreements?" The answer stated, "If you work with (name of OPO) for tissue recovery services, the necessary tissue and eye agreements are included as an addendum to the organ procurement agreement. If you work with another tissue recovery provider, you will need to work with them to ensure you have a separate agreement in place." The contract did not include an addendum related to tissue and eye recovery services.

During an interview on 9/19/14 at 11:00 AM, the Interim Administrator reviewed the contract and confirmed it did not include an addendum related to tissue and eye recovery services. Additionally, he confirmed the facility did not have a contract with another tissue recovery provider.

The facility did not have a contract with a provider of tissue and eye recovery services.

No Description Available

Tag No.: C0347

33951

Based on staff interview, it was determined the facility failed to ensure potential donor families would be approached by an individual trained in the methodology for approaching potential donor families and requesting organ, tissue or eye donation. This had the potential to result in failure of the facility to inform the family of their donation options. Findings include:

During an interview on 9/18/14 at 10:30 AM, the OR Manager stated the facility had employed an MSW who was trained as a designated requestor, however, that individual no longer worked for the facility and another individual had not been trained.

During an interview on 9/18/14 at 4:10 PM, the Interim Administrator confirmed the facility did not employ an individual who had completed a course offered or approved by the OPO.

The facility did not designate and train an individual to approach potential donor families to request organ or tissue donation.

No Description Available

Tag No.: C0349

33951

Based on staff interview and review of personnel records, it was determined the facility failed to work with the designated OPO to educate the facility staff on organ, tissue and eye donation issues for 25 of 25 employees (Staff A to Y) whose records were reviewed. This had the potential to result in failure of the facility employees to identify potential organ, tissue and eye donors, as well as failure to inform potential donor families of their donation options. Findings include:

On 9/18/14, 25 employee files were requested from the Human Resources Director. Inservice and training records were reviewed for each of the 25 employees, which included 12 RNs, 3 LPNs, 1 CNA, 1 PT, 1 Laboratory Manager, 1 Housekeeper, 1 Radiology Technician, 1 RRT, 1 Pharmacy Technician, and 3 Surgery Technicians. No training related to organ, tissue and eye donation issues were recorded in the 25 employee files reviewed.

During an interview on 9/19/14 at 8:30 AM, the Interim Administrator confirmed the facility had not worked with the designated OPO to provide training on organ, tissue and eye donation issues to its employees.

The facility did not provide training to employees regarding donation issues.

No Description Available

Tag No.: C0377

33951

Based on record review and staff interview, it was determined the CAH failed to notify swing bed patients and/or family members, in writing, of discharge dates, the reason for discharge, and the patients' right to appeal the facility's decision to discharge, for 2 of 2 swing bed patients (#1 and #20) whose records were reviewed. This had the potential to result in lack of discharge planning and impeded the patients' opportunity to appeal discharge. Findings include:

Patient #20 was an 89 year old female admitted to a swing bed on 6/12/14, for therapy services following surgery to repair a fracture in her lower leg. Her record was reviewed.

Patient #20 was discharged on 6/19/14, however, her record did not include a written notice of discharge.

Patient #1 was a 54 year old female admitted to a swing bed on 9/12/14, for therapy services following a total knee replacement. Her record was reviewed.

Patient #1 was discharged on 9/15/14, however, her record did not include a written notice of discharge.

The Case Manager who managed swing bed services at the CAH was interviewed on 9/17/14 beginning at 3:15 PM. She stated the CAH had a "Letter of Non-Coverage" to inform swing bed patients of their discharge date, including the patients' right to appeal, however, they had not been using the form. The Case Manager confirmed swing bed patients were not informed in writing of discharge, or of their right to appeal the facility's decision to discharge.

The CAH did not notify swing bed patients, in writing, of their discharge dates, or of their right to appeal the facility's decision to discharge.

PATIENT ACTIVITIES

Tag No.: C0385

33951

Based on staff interview, it was determined the CAH failed to provide an ongoing program of activities to swing bed patients. This resulted in the lack of recreational activities for swing bed patients, and had the potential to result in unmet needs. Findings include:

The Case Manager who managed swing bed services at the CAH was interviewed on 9/17/14 beginning at 3:15 PM. She stated the CAH did not have an activities director, and an activities program was not available for swing bed patients.

The CAH did not have a designated activities director or a program of activities for swing bed patients.

No Description Available

Tag No.: C0388

33951

Based on record review and staff interview, it was determined the CAH failed to complete a comprehensive assessment of the patients' needs, for 2 of 2 swing bed patients (#1 and #20) whose records were reviewed. This had the potential to result in lack of information necessary to develop a care plan and provide services based on the individuals' status. Findings include:

Patient #20 was an 89 year old female admitted to a swing bed on 6/12/14, for therapy services following surgery to repair a fracture in her lower leg. Her record, including the assessment completed at the time of admission, was reviewed.

Patient #20's record included an assessment completed by the RN on 6/12/14. However, the assessment did not include information related to her customary routine, cognitive patterns, mood and behavior patterns, or discharge potential.

Patient #1 was a 54 year old female admitted to a swing bed on 9/12/14, for therapy services following a total knee replacement. Her record was reviewed.

Patient #1's record included an assessment completed by the RN on 9/12/14. However, the assessment did not include information related to her customary routine, cognitive patterns, mood and behavior patterns, or discharge potential.

The Case Manager who managed swing bed services at the CAH was interviewed on 9/17/14 beginning at 3:15 PM. She stated the CAH did not have an assessment tool that was specifically used for swing bed admissions. She stated the admission assessment used for swing bed admissions was the same assessment used for patients admitted to the CAH for acute care. The Case Manager stated she was aware that the assessment did not cover all areas required for swing bed admissions.

Patients admitted to swing beds at the CAH did not receive a comprehensive assessment to determine all of their needs.

No Description Available

Tag No.: C0407

33951

Based on staff interview, it was determined the CAH failed to ensure dental services were available to swing bed patients. This resulted in the potential for patients' dental needs to go unmet. Findings include:

The Case Manager who managed swing bed services at the CAH was interviewed on 9/17/14 beginning at 3:15 PM. She stated the CAH did not have a contract with a provider for dental services and such services were not available for swing bed patients.

Dental services were not available, as needed, for swing bed patients.