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303 NORTH ALLUMBAUGH STREET

BOISE, ID 83704

No Description Available

Tag No.: A0267

Based on staff interview and review of medical records, hospital policies, and quality assurance documents, it was determined the hospital failed to track missed or refused medications in 3 of 3 patient records selected (#4, #5, and #10) for review of held medications. This resulted in missed opportunities for the hospital to analyze the reasons for the missed medications and to determine if the hospital needed to implement any performance improvement measures or change any plans of care. Findings include:

A hospital policy, "Medication Variance," dated 1/09, indicated the hospital maintained a system of reporting, tracking and evaluating medication variances with the purpose of preventing and reducing medication variances. The policy described procedures for how nursing staff were expected to deal with medication variances, including reporting medication variances to the patient's physician and completing a variance form. In the examples that follow, these processes were not followed.

1. Patient #5 was a 56 year old female, admitted on 1/04/10 and discharged on 1/07/10. An initial "History and Physical Assessment," dated 1/04/10, documented a diagnosis of "hyperthyroid secondary to Grave's disease." A "Physician's Order Sheet," dated 1/04/10 at 1:30 PM, documented "Verify Methimazole dose for Grave's disease 5 mg 1 bid" (one two times per day).

A "Medication Administration Record," dated 1/04/10, showed a circle around an 8:00 PM dose of Methimazole on 1/04/10, indicating the dose had not been given. There was no documentation to indicate nursing staff notified the physician of the missed dose or completed a medication variance form to explain and report the missed dose of medication.

The "Medication Administration Record," dated 1/05/10, documented Methimazole was scheduled to be given at 8:00 AM on 1/05/10. An "Interdisciplinary Treatment Note," dated 1/05/10 at 12:10 PM, documented that Patient #5 was anxious about having not had her medication, Methimazole, available earlier in the morning. It further documented the patient received her medication "midmorning." There was no documentation to indicate nursing staff notified the physician of the late dose of Methimazole or that a medication variance form had been completed, per hospital policy.

During an interview on 2/24/10 at 3:50 PM, an RN who was the Manager of the Adolescent Unit and the Infection Control Officer reviewed the record and consulted with the Director of Performance Improvement, and confirmed there was no documentation to indicate nursing staff reported the missed and late doses of Methimazole to the physician. She also confirmed nursing staff did not complete a medication variance form.

2. Patient #4 was a 50 year old female admitted on 12/04/09. A physician's progress note, dated 12/26/09, stated the patient reported she had not been given Paxil at bedtime the night before (on 12/25/09) because the hospital's pharmacy had been closed for Christmas. Consistent with the information in the physician's progress note, the "Medication Administration Record," dated 12/25/09, showed a circle around the 10:00 PM time for Patient #4's dose of medication, indicating the medication had not been given. There was no documentation to indicate the reason the medication was not given, or that nursing staff notified the physician, or that a medication variance form had been completed. During an interview on 2/26/10 at 8:20 AM, the RN Manager of the Adolescent Unit/Infection Control reviewed the medical record and confirmed the findings.

3. Patient #10 was a 30 year old female admitted on 2/13/10. A "Physician's Order Sheet," dated 2/14/10 at 11:05 AM, included orders for bacitracin to be applied daily to abrasions on Patient #10's scalp and right great toe. A "Master Treatment Plan," dated 2/14/10, included a nursing diagnosis of "Altered Skin Integrity as manifested by abrasion to right great toe, superficial lacerations of the wrists and lesions on scalp." Goals included having the patient use the antibiotic as ordered.

Patient #10's "Medication Administration Record" for 2/18/10 and 2/19/10 documented Patient #10 refused the Bacitracin. There was no corresponding note in the record to explain the reason for the refusal, or to indicate nursing staff had notified the physician or completed a Medication Variance form, per hospital policy. During an interview on 2/26/10 at 8:20 AM, an RN who was the Manager of the Adolescent Unit and the Infection Control Officer reviewed the record and confirmed the findings.

The hospital failed to ensure nursing staff followed hospital policy in reporting medication variances.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on record review and staff interview, it was determined the hospital failed to ensure an RN supervised and evaluated the nursing care for 1 of 10 patients (#8) whose records were reviewed. This resulted in inadequate monitoring and follow-through on a patient with an infected finger. Findings include:

1. Patient #8 was a 28 year old female admitted on 2/11/10 and discharged on 2/17/10. A "History and Physical," dated 2/12/10, indicated Patient #8 had a swollen and painful right finger. The plan identified on the H&P was to treat Patient #8 with antibiotics and to have a nurse practitioner anesthetize and lance Patient #8's finger the following day. A Problem List," dated 2/11/10 documented an "infected right finger." A "Master Treatment Plan" included a nursing diagnosis "Altered Skin Integrity as manifested by an infected right index finger," with a goal for healing without exacerbation of symptoms. There was no documentation in the medical record to indicate the finger had been lanced or re-evaluated for continuing signs and symptoms of infection after the initial identification of the problem.

During an interview on 2/25/10 at 10:15 AM, an RN who was the Manager of the Adolescent Unit and the Infection Control Officer reviewed the medical record. She confirmed documentation was lacking to indicate the finger had been lanced or re-evaluated for signs and symptoms of infection.

During an interview on 2/25/10 at 10:45 AM, an NP acknowledged he had been asked by another NP to lance Patient #8's finger. He stated he did not follow through with the procedure because Patient #8's name was not included on his written schedule. He explained that he "covered" 3 hospitals on the weekends and depended heavily on the written schedule to know who to see.

The hospital failed to ensure an RN had supervised and evaluated the nursing care for Patient #8.

FORM AND RETENTION OF RECORDS

Tag No.: A0438

Based on record review and staff interview, the hospital failed to ensure medical records were accurately written or properly filed in 3 of 10 medical records (#1, #3, and #5 ) reviewed. These errors had the potential to interfere with safety and quality of patient care. Findings include:

1. Inaccurate Information:

A. Patient #5 was a 56 year old female, admitted on 1/04/10 and discharged on 1/07/10. An initial "History and Physical Assessment," dated 1/04/10, documented a diagnosis of "hyperthyroid secondary to Grave's disease." At the time of the H & P, the dose of Methimazole Patient #5 had been taking for her Grave's disease was unknown. The plan included having nursing staff verify the correct dose with Patient #5's pharmacy. A "Physician's Order Sheet," dated 1/04/10 at 1:30 PM, documented "Verify Methimazole dose for Grave's disease 5 mg 1 bid" (one two times per day).

The "Medication Administration Record," dated 1/05/10, documented Methimazole was scheduled to be given at 8:00 AM. An "Interdisciplinary Treatment Note," dated 1/05/10 at 12:10 PM, documented that Patient #5 was anxious about not having her medication, Methimazole, available earlier in the morning. It further documented the patient received her medication "midmorning." The "Medication Administration Record," dated 2/05/10 documented the medication was administered at 8:00 AM on 2/05/10. During an interview on 2/24/10 at 3:50 PM, an RN who was the Manager of the Adolescent Unit and the Infection Control Officer reviewed the record confirmed the findings.

A pharmacist was interviewed on 2/24/10 at 4:00 PM. She stated the medication had not been received by the pharmacy in time for the evening dose on 2/04/10 or the morning dose on 2/05/10. She stated the medication was logged into the pharmacy records as having been received at 10:20 AM on 2/05/10. She stated the medication could not have been given at 8:00 AM as it would have been sent to the nursing floor after 10:20 AM when the medication had been logged in as received by the pharmacy.

The hospital failed to ensure accuracy of documentation in the Medication Administration Record.

2. Misfiled Information:

The following two records had patient information from different patient filed in their records. During an interview on 2/24/10 at 12:00 PM, the Director of Medical Records reviewed the records and confirmed the misfilings, stating she would correct the problems.

A. Patient #1 (a closed record) had a medical release form for a second patient filed in her record. She also had lab results for a third patient filed in her record.

B. Patient #3, a current patient, had a physician's progress note for a different patient filed in her record.

The hospital failed to ensure patient record information was properly filed.

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on staff and patient interview and observations, it was determined the hospital failed to maintain its environment in such a manner as to ensure the safety and well being of patients. The findings include:

1. Refer to A701 as it relates to the failure of the facility to maintain the facility in such a manner to ensure patient well-being and safety.

These systemic negative facility practices significantly impeded the ability of the hospital to provide a safe and sanitary environment.

MAINTENANCE OF PHYSICAL PLANT

Tag No.: A0701

Based on observations and interviews with staff and patients, it was determined the hospital failed to ensure 4 of 4 patient units and 1 of 1 kitchen reviewed for environmental issues were maintained in such a manner as to ensure the safety and well-being of patients. The failure to maintain a clean patient care environment directly impacted the psychological well-being of 3 of 3 patients residing in the facility, who voiced environment concerns, and had the potential to impact the well-being of all patients receiving care in these units. Failure to maintain a consistent sanitary environment had the potential to expose patients to sources of infection. Failure to stay current on repairs had the potential to impact patient safety and well-being. The findings include:

1. Patient Interviews

Three of 6 patients interviewed during the investigation expressed concerns about the cleanliness of the physical environment. These concerns are listed below:

A. During an interview on 2/24/10 at 10:15 AM, one patient complained the hospital was "dirty." She stated that when she wore socks and walked about the hospital her socks turned black. She stated the bathrooms had mold in the showers and the walls in the hospital were scuffed and dirty.

B. During an interview on 2/24/10 at 10:35 AM, a second patient stated she had complained to staff about mold in her shower and ants in her unit's lounge. She also stated she understood the hospital was not "like a regular hospital" but she felt it needed to be cleaner.

C. A third patient was interviewed on 2/25/10 at approximately 3:30 PM during a surveyor tour of the hospital's ICU Unit. She stated that staff did not empty the trash consistently and at times it overflowed. She stated that she had personally emptied the trash in a community room on occasions. She proceeded to show the surveyor the walls of the unit. She pointed out splatters, scuffs and dark spots on walls and described some of the spots as "feces." She also stated that she had observed ants in her room. Additionally, she reported that she had found a dirty tampon in her desk drawer and she pointed out coffee stains in another drawer of the desk in her room. She pointed out green, black, and brown stains in her shower and described them to be mold.

2. Observations

A. The Adolescent North Unit was toured on 2/26/10 starting at 10:30 AM. The tour leader, an RN who was the Manager of the Adolescent Unit and the Infection Control Officer, refrained from making comments during surveyor observations. The following concerns were identified:
i. The unit's common area was observed to have food, sticky substances and stains on the walls. The ventilation vent in the room had a thick (approximately 1/8th inch to 1/4 inch) collection of dust and dirt. The hallway and recreation room walls had scattered areas that appeared discolored with dirt and/or scuff marks.

ii. Room #105: The electrical outlet in the bathroom was only secured by one of two screws. The outlet could be pulled from the wall exposing the electrical wires. These wires could be used by patients to hurt themselves. The cover of the outlet was black as if the outlet had arced. This outlet was an electrical hazard and was corrected at the time of the survey in response to a surveyor's request. The sink counter in the bathroom was not level. The counter top was a free hanging countertop that was attached to the wall. It was drooping downward approximately 6 degrees from what appeared to have been caused by excessive weight placed at the outer edge of the counter. The shower faucet and soap dispenser had a build up of soap residual and mineral deposits. Miscellaneous graffiti, such as writing, was observed through-out the room on the walls.

iii. Room #103: The shower contained strips of caulking in the corners that had areas of brown/black discolorations. The faucet and soap dispenser had a build up of soap residual and mineral deposits. Miscellaneous graffiti, such as writing, was observed on walls in the room.

iv. Room #106: The shower faucet and soap dispenser had a build up of soap residual and mineral deposits.

B. The Acute Adult Unit was toured on the afternoon of 2/25/10 and again on the morning of 2/26/10. The tour leader, an RN who was the Manager of the Adolescent Unit and the Infection Control Officer, refrained from making comments during surveyor observations.

i. On 2/25/10 starting at 3:00 PM, Rooms #34, #35, #37 and #38 were observed. All four bathrooms lacked adequate lighting and ventilation. Each bathroom had a single light that could not directly illuminate the shower. Further, when the shower curtain was pulled closed, light had little ability to illuminate the inside of the shower due to the lack of transparency of the curtain covering the shower entrance. The strips of caulking along the corners inside the showers were observed in room #34, #35 and #37 to have black and brown discolorations scattered in varying amounts from a few inches to a few feet. Additionally, there were small spots of peeling paint on the ceiling of the shower in Room #34.

ii. The hospital's Acute Adult Unit's hallway was observed to have dark, brown and black discolorations on the tile where the wall met the floor.

iii. On 2/26/10 starting at 10:00 AM, the hospital's Acute Adult Unit was revisited. A trash can by the nursing station was noted to have dried liquid splattering covering the outside. The walls in the Acute Adult Unit group room had occasional, scattered areas of dried fluid splatters and food. A trash can was noted to have dried fluid splattering covering the outside and 1/2 of the wall behind the trash can was also covered with dried fluid splatters.

iv. Room #33: The toilet paper dispenser had a thick white residual, dulling and covering the chrome. The strips of caulking in the shower had areas of brown/black/blue discolorations. There were screw-size holes in the wall. The bathroom baseboard was pulling away at points. Additionally, some of the formica was missing on the areas next to the sink.

v. Room #35: The shower contained strips of caulking that had areas of brown/black/blue discolorations. The ceiling paint in the shower had small areas of peeling throughout. The ceiling was very moist and soft upon touch as if some of the surface had eroded. Holes in the wall from old screws were noted and a wall near the toilet was noted to be wet with peeling paint. The toilet paper dispenser had a thick white residual, dulling and covering the chrome. Additionally, the baseboard in the bathroom was pulling away at points.

C. The ICU West Unit was toured on the morning of 2/25/10 and afternoon of 2/26/10. The tour leader, an RN who was the Manager of the Adolescent Unit and the Infection Control Officer, refrained from making comments during surveyor observations.

i. On 2/25/10 starting at 3:45 PM, debris, including orange peels, were noted on the hallway floor.

ii. Room #13: The room was unoccupied. The bathroom had a musty smell. The bathroom was observed to be moist with water dripping from the ceiling and walls throughout the entire bathroom. The shower head was dripping continuously and would not turn off. The inside of the shower had black and brown spots scattered on the wall and on the strips of caulking in the corners. Between surveyor observations on 2/25/10 and 2/26/10, the hospital fixed the faucet and cleaned the bathroom.

iii. On 2/26/10 starting at 9:30 AM, the hospital's ICU West Unit was revisited. It was noted the showers had unvented ceiling overhangs (approximately 5 x 5 x 3 foot). This area retained moisture. For example, in the shower in Room #15 there were numerous small spots on the shower ceiling where paint was peeling away and other areas of paint were bulging away from the ceiling. When the bulging paint was removed by the surveyor, black residual was observed under the paint. Additionally, the bathroom baseboard in front of the sink was pulling away at several spots from the base of the sink. The bathroom sink counter had broken and missing laminate exposing the wood top of the sink countertop.

D. The ICU Unit was toured on 2/26/10 starting at 9:40 AM. The tour leader, an RN who was the Manager of the Adolescent Unit and the Infection Control Officer, refrained from making comments during surveyor observations.

i. The unit's common area was observed to have food, sticky substances, stains and small areas of missing paint on some areas on the walls. The ventilation vent in the room had a collection of dust and lint (approximately 1/8 inch to 1/4 inch thick). The floor was observed to have food debris and a collection of dust/dirt in the corners and at the base of the door frames. The adjoining bathroom had multiple dried wads of toilet paper stuck to the ceiling. There were multiple screw size holes on the bathroom walls.

ii. Room #25: The base trim moulding was observed in the bathroom. The trim had areas that were pulling away from the wall. Dust bunnies were observed in the bathroom corners. Additionally, holes were observed in the wall from old screws. The toilet paper dispenser had a thick white residual, dulling and covering the chrome. The shower contained areas of brown discolorations that dissipated upon rubbing in the corners in the shower.

iii. Room #26: A paneling measuring approximately 3 foot by 3 foot, that covered the plumbing beneath the bathroom sink was observed to be falling off, exposing 4 wood screws. The screws could be used by patients to hurt themselves and presented a safety hazard. The toilet paper dispenser had a thick white residual, dulling and covering the chrome. The shower contained strips of caulking that had areas of brown/black discolorations.

E. The kitchen was toured on 2/26/10 starting at 10:30 AM. The Dietary Manager was present during the tour. The following observations were noted.

i. The juice dispenser had thick dried juice above each dispensing outlet.

ii. Mineral deposits were noted above the outlet of the water dispenser.

iii. The ice cream machine had dried milk products within the interior of the machine.

iv. The cappuccino machine had dried milk/coffee products on the interior of the machine.

v. The coffee dispenser had dried coffee products within the interior of the machine.

vi. About a 1/2 inch thick food/sheet-rock dust build-up was observed in the corners of the service kitchen window track.

vii. Food particles were on the foot of an industrial mixer.

viii. A mop bucket drain with splash boards was pulling away from the wall and the sink had multiple cracks. Further, there were areas in the mop drain sink that had brown/black/blue discolorations.

ix. The ice maker had mineral deposits above the ice on the roof of the machine.

x. The wash room had brown/black/blue discolorations along the walls and floor.

xi. A vent had lint build up over the dishwasher. The floor was stained.

xii. A drain pipe from a kitchen sink was noted to be plumbed to an open floor drain. The pipe was resting on the bottom of the open drain. Plumbing draining systems should be installed to prevent the backflow of a solid, liquid, or gas contaminant into the water supply system at each point. Drains need to be installed to provide an air gap between the floor drain and the piping. The Dietary Manager confirmed the observations noted above. During an interview on on 2/26/10 starting at approximately 10:40 AM, the Dietary Manager stated that the pipe usually sits on a block that lifted it. She stated that because of its location and a door, the door knocked the pipe off the block every time the door was opened.

4. Staff Interviews

A. On 2/26/10 starting at 11:30 AM, the hospital's Housekeeping Supervisor was interviewed. She stated she had the equivalent of 3 full time and 1 half time housekeeping staff working per day working from 6:30 AM to 3:00 PM, Monday through Friday and 2 housekeeping staff on the weekend who worked the same hours. She stated that after 3:00 PM it was up to the nursing staff to perform housekeeping duties. However, job descriptions for nursing and psychiatric technician staff failed to include housekeeping duties.

The hospital's Housekeeping Supervisor further stated that at one time the housekeeping staff included a "deep cleaner," but they had not had that position for about a year and a half. She stated she and her staff could barely keep up with the daily cleaning duties in the time that had been allotted to clean. She stated she and her staff did not regularly have the time to do detailed cleaning. For example, she stated the air vents were to be cleaned weekly but she and her staff rarely had time to do them as evidenced by surveyor observations. She denied any policies and procedures had been developed related to housekeeping. She denied having a written list of daily tasks to be performed, although, she stated, she knew what tasks needed to be completed. She stated that she did not have a competency checklist for housekeeping staff; however, since she was a working supervisor, she had observed the work of housekeepers under her supervision. She stated she had no involvement with training nursing staff on how to perform housekeeping duties when housekeeping was not available.

B. On 2/26/10 starting at 11:15 AM, a hospital maintenance mechanic was interviewed. He stated that he had been working for the facility for 22 years. His job responsibility was to ensure the daily maintenance of the building and he also was responsible for some yard work. He stated that 3 months prior the hospital let go of a second maintenance mechanic and did not rehire the position. He stated that he worked in "reactive mode" in response to work orders initiated by staff. He did not have time for routine or preventive maintenance. For example, he stated the bathroom caulking was to be removed and replaced yearly. He stated that with his current workload he would not likely have time to perform that duty and be able to respond to the daily work order requests.

C. On 2/26/10 starting at 11:30 AM, the hospital's Plant Operations Manager, who oversaw Maintenance and Housekeeping, was interviewed. In response to surveyor questions regarding observations about the conditions of the showers, he confirmed the lack of ventilation in the showers in 3 of the older units. He stated that the caulking in the showers had been replaced about a year prior because of similar problems but because of the shower design, the problem had recurred. He explained that the hospital planned to replace the showers entirely but until that was done it was necessary to replace the caulking nearly yearly and the showers were hard to keep clean.

When asked about the screw holes observed in the walls, he stated that they would be corrected when other issues were identified as needing attention in the individual rooms that had the screw holes.

He stated that dirt had a tendency to collect along the edges of the tile in the hallways because when the tile was installed, the edges did not reach the walls and there was a gap between the tile and the wall moulding. He stated the problem would be corrected when the hospital was able to replace the flooring. In the meantime, he acknowledged, it was difficult to keep clean.
He also stated that because housekeeping staff left at 3:00 PM daily, he recognized that trash tended to build up in the evenings until early morning when housekeeping staff could re-empty them. He stated that since housekeeping staff was not there in the evenings, nursing staff was left to clean rooms when a patient was discharged and the room was needed to admit another patient. He stated he thought it would be helpful to have housekeeping staff working until about 9:00 PM to allow better coverage of cleaning needs.

D. On 2/26/10 starting at 11:13 AM, the hospital's Chief Financial Officer was interviewed. He acknowledged the facility had aged and explained that it was in the hospital's 3 year plan to remodel the older units. He expressed disagreement with surveyors' conclusions about lack of cleanliness and stated he felt the facility was clean and well maintained.

The hospital failed to ensure its physical environment was maintained adequately to ensure the safety and well-being of patients.