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Based on a review of medical records and staff interview, it was determined the hospital failed to ensure patients and/or their representatives admitted to the ED were informed of their patient rights for 15 of 17 patients (#13-14, 25-32, 35, and 37-40) who were admitted to the ED and whose records were reviewed. This had the potential to interfere with awareness and understanding of patient rights and prevented the hospital from promoting and protecting each patient's rights. Findings include:

The medical records of Patients #13-14, 25-32, 35, and 37-40 contained a form labeled "Conditions of Admission of Kootenai Medical Center." There was no patient rights information on this page or other documentation that patients were informed of their rights.

The Regulatory Compliance Coordinator was interviewed on 10/30/19, beginning at 4:15 PM. She confirmed that ED records did not contain documentation stating patients were informed of their rights at the time of admission to the ED.

The hospital failed to ensure patients admitted to the ED were informed of their rights.

Based on review of complaints and grievances and hospital policy, and staff interview, it was determined the hospital failed to send follow-up letters to complainants whose concerns were misclassified as complaints rather than grievances for 2 of 5 complainants (Complainants #2 and #4) whose documented concerns were reviewed. This resulted in incomplete resolution of the grievance process. Findings include:

A hospital policy, "Patient Grievance Policy," dated 8/22/17, included the following definitions:

"Complaint - An issue considered resolved by staff present that does not require investigation when the patient is satisfied with actions taken on their behalf, or the nature of the complaint does not meet the definition of a grievance."

"Grievance - A formal or informal written (written communication is always considered a grievance) or verbal complaint (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient or patient's representative, regarding any of the following:

- The patient's care,
- Abuse or neglect,
- Issues related to the organization's compliance with the CMS Hospital Conditions of Participation..., or
- A Medicare beneficiary billing complaint related to rights and limitations provided 2 CFR 489."

"When the patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to another staff member for later resolution, requires investigation, and/or required further actions for resolution then the complaint is a grievance."

The hospital "will send written communication to the patient and/or the patient's representative within 7 days of the receipt of the grievance. This written communication shall outline the results of the investigation and actions taken therein."

Grievances were misclassified as complaints. As a result, patients or their representatives were not provided with a written response.
Examples include:

1. A "Patient Relations Entry," 9/08/19, for Complainant #2 stated a complaint came in from a patient through the "CONNECT" system. Complainant #2 alleged he was not told how to procure medical equipment he needed at home to aid in his recovery and that he had requested a consult with a social worker [during hospitalization] but one did not show up until discharge. He stated he was sent home and did not initially have necessary medical equipment and had to spend his first day of recovery driving to procure it.

Complainant #2's concerns met the definition of a grievance as he alleged discharge planning needs were not met, despite his request during his hospitalization for a social work consult. The complaint required investigation to determine what happened and to prevent similar discharge planning issues from occurring again. No follow-up letter was sent to Complainant #2.

The Patient Advocate was interviewed on 10/29/19 at 11:15 AM. She stated, the concern was automatically classified as a complaint (rather than a grievance) because it came in through the CONNECT system. She stated the nurse manager was notified of the complaint and "we should have forwarded this to social services for review."

The hospital did not send written notice of follow-up to Complainant #2, whose concern met the regulatory definition of a grievance.

2. A "Patient Relations Entry," dated 9/13/19, documented Complainant #4's multiple complaints regarding care (during her stay in January, 2019), staff attitude and treatment, and parental rights. Additional documentation, dated 9/17/19, indicated the complainants record was reviewed and it was determined her infection did not meet criteria for a hospital acquired infection.

The complaint was not listed as a grievance and there was no follow-up letter sent to Complainant #4.

The Patient Advocate was interviewed on 10/29/19 at 11:15 AM. She stated Complainant #4's concerns were sent for review to medical staff office and infection prevention unit manager for review. She explained Complainant #4's concerns were classified as complaints rather than grievances because her concerns were triggered by an article in a newspaper and Complainant #4 did not want follow-up. She confirmed documentation did not reflect Complainant #4's refusal of a follow-up letter after investigation.

The hospital did not send written notice of follow-up to Complainant #4, whose concern met the regulatory definition of a grievance.

Based on review of hospital policy, patient rights information, and staff interview, it was determined the hospital failed to ensure the hospital honored advance directives, or alternatively provided notice, in advance of same day hand surgery, that included a clear and precise statement of limitation to implementing an advance directive for 1 of 1 off-campus same-day surgery center, whose processes were reviewed. This had the potential to interfere with patients' ability to consent to informed decision-making. Findings include:

A hospital policy, "Advance Directives," dated 4/24/19, stated the hospital "respects the right of patients to formulate Advance Directives and follows the wishes of patients when they are known." The section of the policy that addressed day surgery patients, including the outpatient clinics, did not address any limitations to honoring advance directives.

Patient rights information provided to patients by the outpatient Hand Clinic was reviewed. The documents did not notify patients of any limitations to honoring advance directives, in the event patients had a POST or other advance directive indicating they did not want resuscitation.

The RN Supervisor of the outpatient Hand Clinic, where day hand surgery was conducted, was interviewed on 10/31/19 at 11:30 AM. When asked how they handled advance directives, he stated, "we always resuscitate."

The hospital's outpatient Hand Clinic did not honor advance directives or communicate their policy to suspend advance directives during outpatient surgery in the clinic.

Based on review of patient rights documents and staff interview, it was determined the hospital failed to ensure a process was in place to ask patients if they wanted their own personal physician notified promptly of their admission to the hospital. This impacted all inpatients, except those admitted to behavioral health units. This interfered with the exercise of patient rights and had the potential to interfere with the ability of patients to coordinate their healthcare needs. Findings include:

A hospital document, "PATIENT RIGHTS & RESPONSIBILITIES," revised 7/2019, stated, "As a patient you are entitled to:...Be assured your physician...will be promptly notified when you are admitted."

There was no documentation in inpatient records, except the behavioral health unit, that patients' physicians were notified of their admissions.

The Manager of Patient Access was interviewed on 10/30/19 at 3:20 PM. He stated it was the hospital's practice to obtain physician information at registration. He denied any practice of physician notification after admission, and stated physicians were sent discharge summaries after patients discharged from the hospital.

An RN Informatics Analyst was interviewed on 10/30/19 at 3:40 PM. When asked where in the medical records we could find documentation physicians were notified of patient admissions or patients were asked if they would like to have physicians notified of their admission, she stated she was not aware of any specific nursing process for physician notification of admission.

The Regulatory Compliance Coordinator was interviewed on 10/30/19 at 5:00 PM. She confirmed the hospital did not have a policy or procedure established for physician notification after admission.

The hospital failed to ensure patients were given the opportunity to have their own physicians notified promptly of their admissions to the hospital.

Based on observation, review of hospital policy and ligature risk assessment information, and staff interview, it was determined the hospital failed to ensure ligature risk was eliminated from behavioral health units. This had the potential to affect safety of patients on the behavioral health units who were inclined toward self-harm. Findings include:

A hospital document, "PATIENT RIGHTS & RESPONSIBILITIES," revised 7/2019, stated "As a patient you are entitled to:...Receive care in a safe setting..."

A policy was requested that addressed ligature risk.

A policy, "Behavioral Health Safety Walkthrough," was provided. It stated, "Any ligature point noted on either the adult or youth psychiatric units during daily walk-throughs will be immediately escalated to the Charge Nurse, Manager and Director of Behavioral Health. Immediate notification to the Facilities Department will occur to correct the risk and 1:1 observation will be put into place for the protection of suicidal patients until the ligature point is abated."

Additionally, a "Patient Safety and Ligature Risk Checklist: Common Areas," documented potential ligature risks: very low risk (1-3), low risk (4-6), moderate risk (7-12), and high risk (13-25). Light fixtures were rated a level 6, with comments "can provide anchor points if fixtures are not properly designed. If damaged, parts can be used as a weapon." Door tops were rated a level 5, with comments "by tying a knot in a rope or sheet and lodging it over a closed door, patients can use door tops as an anchor point. Tops should be monitored or cut to eliminate ligature opportunity."

During an RN surveyor observation of the adult Behavioral Health Unit on 10/29/19 at 3:00 PM, multiple overhead lights were observed in hallways, with straps around them, that could be potential ligature risks. During the observation, the Director of the Behavioral Health Unit stated the hospital had ordered replacement lights but did not expect them to arrive until mid-December, 2019. During the course of the survey between 10/29/19 and 11/01/19, the hospital removed straps from the lights and secured the light covers with safety screws to reduce the risk of patient's pulling off the covers and using light bulbs as weapons to harm themselves or others.

During an observation by the Life Safety Code surveyor on 10/31/19, door tops and handles on the unit were noted to be potential ligature risks. The Lead Facility Services Supervisor, the Facilities Director, and the Behavioral Unit Manager were present for the observation.

The hospital failed to ensure the behavioral health units were free of ligature risks.

Based on policy review, record review, and staff interview, it was determined the hospital failed to ensure a physician's order described the type of restraint being ordered for 1 of 2 patients (Patient #13) who had restraint orders in an ED setting and whose records were reviewed. This resulted in a lack of clarity as to the restraint being ordered. Findings include:

A hospital policy, "Restraint and Seclusion," dated 11/30/17, included physician order requirements to identify the type of restraint.

Patient #13 was a 36 year old male who arrived with a caregiver at the ED on 9/13/19 for a psychiatric evaluation related to aggressive behaviors. Physician documentation, dated 9/13/19, ordered chemical restraints and "physical restraints." The chemical restraints were specified. However, the type of physical restraint was not specified.

Patient #13's restraint documentation was reviewed with the Youth Service Program Director of the Behavioral Health Unit on 10/28/19 at 3:00 PM. She stated the physician's order for "physical restraint" should have specified "physical hold" as that was the type of restraint documented. She confirmed the order was unclear.

A restraint order for Patient #13 was not written in accordance with hospital policy.

Based on review of hospital policy, medical staff credentialing files, and staff interview, it was determined the hospital failed to ensure physicians or other LIPs attested to a working knowledge of restraint and seclusion policy for 10 of 19 physicians or LIPs (Staff B, E, G, H, J, K, L, M, N, and P) who had inpatient privileges and whose credentialing files were reviewed. This resulted in a lack of clarity as to whether the physicians or LIPs had a working knowledge of restraint policy and it had the potential to interfere with the appropriate care of patients who required restraints or seclusion. Findings include:

A hospital policy, "Restraint and Seclusion," dated 11/30/17, stated, "Physicians that order restraints or seclusions will be educated about Kootenai Health's restraint and seclusion policy to have a working knowledge of the policy."

A surveyor reviewed credentialing files, on 10/31/19 beginning at 9:30 AM, of a sample of 19 physicians and other LIPs with the Director of the Medical Staff and the Credentialing Coordinator. The following physicians and LIPs credentialing files did not include documentation of restraint training or an attestation of a working knowledge of restraint and seclusion policy: Staff B, E, G, H, J, K, L, M, N, and P.

The Director of the Medical Staff was interviewed at the time of credentialing review on 11/01/19 at 8:30 AM. She stated since 2016 the hospital required all physicians and LIPs to attest to a working knowledge of restraint policy, regardless of whether they ordered restraints or not. She stated there was no specific privilege given related to restraints or seclusion. She confirmed attestations were missing in the above referenced credentialing files. She explained that these practitioners were on staff prior to 2016 and the hospital did not go back and require an attestation for individuals who were on staff prior to 2016, but would do so in the future.

The hospital failed to ensure documentation showed physicians and LIPs had a working knowledge of the hospital's restraint and seclusion policy.

Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure complete pain assessment documentation for 1 of 17 ED patients (Patient #39) whose medical records were reviewed. This had the potential to negatively impact coordination, quality, and safety of patient care after the patient discharged to home. Findings include:

A hospital policy titled, "Pain Management" with an effective date of, 03/13/2017 was reviewed.

The policy for a comprehensive pain assessment stated:

"1. A comprehensive pain assessment will be conducted & documented in the pain assessment screen by the RN on admission to the hospital, following changes in level of care...

Location
Nature of pain - character of pain
Duration
Type
Intensity
Aggravating factors
Any pain relief methods that have proven effective
The patients' resting pain goal
The patient's pain score
The patient's pre-hospitalization history of pain, analgesic use, response to pain therapy, medication tolerance & history of substance abuse"

The policy for On-going pain assessment stated:

"1. The patient will undergo reassessment of pain...at least every 4 hours...Patients experiencing severe pain (rating a 7-10/10 on the numerical scale) and those at high risk for adverse effects need pain assessments more frequently than every 4 hours.

2. The On-Going Pain Assessment will include but is not limited to the following:

a. Location
b. Nature of pain - character of pain
c. Duration
d. Type
e. Intensity
f. Aggravating factors
g. The patients' resting pain goal
h. The patient's resting pain score"

Patient #39 was an 11 year old male admitted to the ED on 10/25/19 at 7:00 PM, with an admitting diagnosis of MVC (motor vehicle collision)/ROLL OVER.

The ED Triage Assessment included:

"Description of symptoms: patient was in a quad rollover around 4:00 PM; patient states he was 'launched about 20 feet'; unknown LOC; no helmets; patient c/o (complains of) pain in R flank and L shoulder/neck, head.

Physical Exam-Constitutional: Other (Patient is in extreme amount of distress due to the ATV (all terrain vehicle) he is in tears due to pain."

A pain assessment in Patient #39's record at 7:35 PM, documented:

"Pain location: R flank/hip, L should/neck, head
Pain rating (0-10): 10
Pain Description: aching
Pain Duration: acute
Level of Sedation: Awake and Alert
Management Techniques taken to Relieve Pain: Environmental Family Support."

The patient's resting pain goal was not documented as required by policy. No additional pain assessments/reassessments were documented in his chart prior to his discharge at 11:14 PM. Documentation under patient education included the note, "Grandmother handed discharge paperwork with verbal education. Grandmother will use ice and Tylenol for pain."

Nursing staff failed to completely assess and then reassess Patient #39's pain, evaluate patient care, and determine response to interventions.

The ED Nurse Manager and the Director of the ED were interviewed on 11/01/19, beginning at 8:20 AM. They confirmed the missing elements of the pain assessments as well as absence of reassessments/evaluation or interventions by the nursing staff.

Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure medical records contained complete documentation including a Crisis Response Plan (Safety Plan) in 1 of 17 ED patients (Patient #29) whose medical records were reviewed. This had the potential to negatively impact coordination, quality, and safety of patient care after the patient discharged to home. Findings include:

A hospital policy, "Management of the Patient Requiring Psychiatric Evaluation in the Emergency Department" dated 07/26/2017, was reviewed. It stated for discharge from the ED, "the patient must be sent home with a Safety Plan completed by the EDP (Emergency Department Physician), KBH (Kootenai Behavioral Health) case manager or RN. A signed copy must be retained in the patient's medical record."

Patient #29 was a 19 year old male admitted to the ED, on 10/20/19 on a police hold, with an admitting diagnosis of suicidal ideation and a chief complaint of "Suicidal Ideation/Attempt." His record was reviewed. He was placed on every 15 minute observation checks.

The ED Triage Assessment that included the following documentation:

"Physician note: the patient presented on a PC (protective custody) hold last night for concerns of endorsing S.I. (suicidal ideation) with intentions to use a knife to inflict self harm...then grabbed a knife and planned to inflict cut [sic] himself, however a staff member intervened. The pt. has a history of chronic suicidal ideation with a self harm history.'
Psychosocial/Safety assessment note: 'pt wanted to cut his wrists, pt states he was having family issues'
Current thoughts of Harming Self - Yes
Suicide Attempt/Mutilation in the past - Yes - OD (overdose) on pain medications.
Suicide Ideation Frequency scored 2-5 times a week"

The discharge disposition referenced "safety plan hand carried" and under "Activity Restrictions/Additional Instructions" included "Follow up per KBH safety plan" The record did not include a copy of the hospitals' "Crisis Response Plan" (Safety Plan) that included a list of "specific activities or actions you can take to commit to living," contact information/instructions if the patient found themselves in crisis and thinking about suicide as well as follow up recommendations.

During an interview on 10/30/19 beginning at 4:15 PM, an RN case managerconfirmed that a patient with an admitting ED diagnosis of Suicide Ideation should have a completed Safety Plan with a copy sent home with the patient at discharge and a copy added to the patient's medical record.

During an interview on 10/31/19 beginning at 3:10 PM, an Informatics RN and a Risk Management RN confirmed that the Crisis Response Plan (Safety Plan) was not part of Patients #29's record and they could not provide proof that it was sent home with him at discharge.

The hospital failed to properly file and retain documentation of Patient #29's Crisis Response Plan (Safety Plan).

Based on review of agency policy, nurse initiated order sets, and staff interview, it was determined the hospital failed to ensure the approval process for nurse initiated order sets included review by all required disciplines and demonstrated the protocols were consistent with nationally recognized evidence-based guidelines. This impacted 5 of 6 nurse initiated order sets (A, B, C, D, and F) that were reviewed. This had the potential to negatively impact safety and quality of patient care. Findings include:

Hospital policy, "Nursing Initiated Order Sets," revised 3/2015, stated, "Nursing Initiated Orders Sets must define/include...Current evidence-based references used in its development." It also stated, "All nurse initiated order sets must be approved by the appropriate medical staff and nursing committees before being available for use. Pharmacy approval for all medication use in order sets is required." The regulation requires pharmacy leadership approval whether medication is or is not involved. Hospital policy differed from this regulatory expectation.

The surveyor requested copies of all nurse initiated order sets. Six order sets were provided for review, including:

A. "Outpatient CTS PreOp NIO"
B. "Neo NIO Admit"
C. "Adult CC NIO Elec. Rep Prtcl"
D. "ED NIO: Epistaxis"
E. "ED NIO: Rapid EKG"
F. "Adult OB NIO Triage"

Order set requirements for development and review were not followed. Examples include:

1. The nurse initiated order set, "Outpatient CTS PreOp NIO," 6/14/19, did not include documentation of evidence-based references used for development or review. It also did not include documentation of the approval process.

2. The nurse initiated order set, "Neo NIO Admit," 6/14/19, did not include documentation of evidence-based references used for development or review. One physician reviewer comment documented "approve, with change to sucrose as commented on by Mary." There were no other specific documented approvals of the order set by nursing or pharmacy leadership.

3. The nurse initiated order set "Adult CC NIO Elec. Rep Prtcl," dated 6/17/19, did not include documentation of evidence-based references used for development or review. The comment stream included comments from laboratory and pharmacy personnel without specific documentation of approval. A third party RN documented approval by a physician. There was no documentation of nursing leadership review and approval.

4. The nurse initiated order set "ED NIO: Epistaxis," dated 2019, did not include documentation of evidence-based references used for development or review. It included a comment stream without specific approvals.

5. The nurse initiated order set "Adult OB NIO Triage," dated 6/14/19, did not include documentation of evidence-based references used for development or review. It included RN approval, without any specific documentation of approvals from a physician or pharmacist.

The Clinical Informatics Manager and the Regulatory Compliance Coordinator were interviewed together on 11/01/19 at 8:40 AM.
The Regulatory Compliance Coordinator confirmed the hospital's policy had not been updated to reflect the requirement for pharmacy approval of all standing orders. She stated they were aware of this requirement. They confirmed the lack of clear documentation as to the approval process and the guidelines used to develop the order sets. The Clinical Informatics Manager stated, "we can tighten up approval."

The hospital failed to ensure nurse initiated order sets were developed and revised based on clear evidence based clinical practice guidelines and that all approvals were obtained and documented prior to initiation of the order sets.

Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure written consent forms for procedures and anesthesia were properly executed for 1 of 1 patient (Patient #23) for whom consent was obtained by phone and whose record was reviewed. This had the potential to result in treatment being provided without the verified consent of the patient's representative. Findings include:

The hospital's policy, "Informed Consent," effective 11/16/16, stated, "Informed consent will be obtained for a patient to undergo a treatment or diagnostic procedure at Kootenai Health to include:

a. All surgical and invasive procedures
b. High-risk procedures
c. Blood transfusions
d. Sedation..."

Additionally, the policy stated, "Telephone - If a patient is unable to give informed consent, a reasonable attempt will be made to gain telephone informed consent utilizing 2 witnesses' signatures (Kootenai Health staff.)"

Patient #23 was a 40 year old male admitted to the hospital on 9/26/19, with an admitting diagnoses of acute renal failure, shock, and altered level of consciousness. He expired on 9/28/19.

1. Patient #23's record included a procedure report for a gastroscopy, signed by the physician on 9/27/19. It stated consent for the procedure was obtained by phone from Patient #23's mother. His record included an informed consent for "Gastroscopy with anesthesia." It stated, "Verbal consent from [name] (mother)." The consent included an RN's signature, dated 9/27/19, as witness to the consent received. It did not include a signature of a second witness.

2. Patient #23's record included a consent for anesthesia that stated, "mother - telephone consent." The consent included an RN's signature, dated 9/27/19, as witness to the consent received. It did not include a signature of a second witness.

During an interview on 10/31/19 at 11:15 AM, the Patient Safety Specialist reviewed Patient #23's consent forms. She confirmed the consents for gastroscopy and anesthesia were obtained by phone from Patient #23's mother, and did not include the signatures of 2 witnesses as required by hospital policy.

The hospital failed to ensure consents received by phone from Patient #23's representative were properly witnessed.

Based on observation, review of hospital guidelines, and staff interview, it was determined the hospital failed to ensure kitchen staff properly stored and labeled food in the hospital's dietary department. This had the potential to compromise patient safety and nutritional value of food. Findings include:

A policy related to food storage in the dietary department was requested. Two documents were provided, as follows:

1. A document titled, "Guidelines for Labeling, Dating, and Tossing of Food," dated 3/26/09, stated, "Items prepped for use: Label with date the food item was prepped and the last date the item is to be used by."

2. A document titled, "Nutritional Services," developed 2004, last reviewed July, 2014, stated, "Food stored in the refrigerator must be labeled. Label must contain the name of the food and the date it was first served or prepared."

A tour of the hospital's dietary department was completed on 10/29/19 beginning at 10:30 AM, with the hospital's chef. A container of single serve salad dressings, in small plastic containers with lids, was observed in the kitchen's walk in cooler. On the front of the container there was a piece of blue tape with the handwritten date 10/31/19. The chef stated it was a "use by" date, indicating the salad dressings could be served for 2 more days. Next to the container of salad dressings was a large container of chopped lettuce, identified by the chef as Asian salad. On the front of the container there was a piece of blue tape with the handwritten date 10/27/19, 2 days prior. The chef stated it was a "prepared on" date, not a "use by" date. There was no difference in the appearance of the labels identified as "use by" and "prepared on." The hospital's chef confirmed the 2 labels looked the same and it could not be determined if they were "prepared on" or "use by" dates.

On 10/29/19 at 10:50 AM, the Nutrition Services Manager observed the labeled containers of single serve salad dressings and Asian salad. She confirmed it was not possible to distinguish "use by" dates from "prepared on" dates.

The hospital failed to ensure prepared foods were properly labeled to determine the date they should be discarded.

Based on observation, policy review, and staff interview, it was determined the hospital failed to develop and implement a comprehensive water management plan. Failure to develop and implement a facility specific water management plan increased the risk of growth and spread of opportunistic pathogens in building water systems. This had the potential to expose patients, staff, and visitors to water source bacterium. Additionally, the hospital failed to identify potential infection risks for patients, personnel, and visitors, and ensure clinical staff followed effective infection control practices. This resulted in inadequate interventions to mitigate environmental and surgical infection risks. Findings include:

1. The hospital's water management plan was reviewed by the Life Safety Code surveyor with the hospital's Director of Engineering on 10/31/19, from approximately 11:30 AM to 12:00 PM. The plan's risk assessment did not identify the boilers and chillers used in the HVAC (heating, ventilation, and air conditioning) system and sterilization/processing system as risks for potential transmission of waterborne pathogens.

The Infection Prevention Manager was interviewed on 11/01/19, beginning at 9:00 AM. Documentation of the identification of the boilers and chillers in the hospital's risk assessment plan was requested, none was provided.

2. A hospital policy, "Hand Hygiene and Hand Antisepsis," effective date 1/05/18, stated the indications for handwashing and antisepsis included: "Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse of [sic] blood pressure, and lifting a patient) ... Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient ... Decontaminate hands after removing gloves." The policy was not followed. An example includes:

Patient #48 was a 66 year old male admitted on 10/30/19, for laparoscopic hernia repair. His surgical procedure was observed on 10/30/19, beginning at 10:50 AM.

During the procedure, a CRNA was observed removing his gloves after assisting with the transfer of Patient #48 to the operating table then, without performing hand hygiene, he used a pen and clipboard to document, handled medication syringes and the IV (intravenous) port and, at the end of the procedure, donned new gloves before extubating Patient #48.

The Infection Prevention Manager and 2 Infection Preventionists were interviewed together on 10/31/19, beginning at 1:00 PM. They confirmed the observed actions did not follow the hospital's hand hygiene policy.

3. A tour of the hospital was conducted in the presence of an Infection Preventionist on 10/31/19, beginning at 11:30 AM. During the tour, infection control issues were identified. Examples include:

a. In 3 of the hospital's public restrooms (1 located on the first floor of the Administrative Services building and 2 in the critical care waiting room), an automatic paper towel dispenser was installed above a waste bin. Clean paper towels were observed dispensing from the automatic dispenser into the waste bin and its contents.

b. An automatic paper towel dispenser in the NICU Milk Soiled room was installed above the counter. Clean paper towels were observed dispensing from the automatic dispenser onto the counter. The unsanitary surface in the "soiled" room had the potential to contaminate the towels.

The Infection Preventionist was interviewed on 10/31/19, beginning at 12:10 PM. She confirmed the infection control issues with the contact between clean towels and contaminated surfaces.

Based on medical record review and staff interview, it was determined the hospital failed to ensure a list of available home health agencies was given to 1 of 3 of patients (Patient #43) referred to home health agencies whose records were reviewed. This resulted in a lack of clarity as to freedom of choice among home health providers of care. Findings include:

Patient #43 was a 91 year old female admitted to the hospital on 8/05/19 for hip surgery. She was discharged on 8/06/19 to home health services. RN discharge documentation, dated 8/06/19, documented Patient #43 was referred to a specific home health agency.

Patient #43's medical record included a form, "KOOTENAI COUNTY REFERRAL," that marked 2 of 7 listed home health agencies as "1" and "2." There was no documentation the list of options was presented to Patient #43.

An RN Case Manager was interviewed on 10/31/19 at 2:05 PM. She reviewed Patient #43's record and stated Patient #43 "did not have a preference, we would have picked one randomly." She confirmed there was no documentation the list of choices was provided.

The hospital failed to ensure a list of available home health agencies was presented to Patient #43 to ensure choice was given.