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Based on observation, policy review, medical record review, staff as-worked schedule review, personnel file review, review of RN licensure, and staff interview, it was determined the hospital failed to provide emergency care necessary to meet the needs of its inpatients and outpatients. This resulted in a lack of emergent care to 1 of 1 inpatient (Patient #32) who had a cardiopulmonary arrest and died, and whose record was reviewed. Additionally, this resulted in expired emergency medicines and supplies throughout the hospital and had the potential for adverse care for all hospital inpatients and outpatients. Findings include:

1. A hospital policy titled "Code Blue - Cardiac Arrest," approved 10/01/20, stated, "If a patient is found unresponsive and is not breathing or is only gasping, immediately activate the emergency response system. After activation the health care provider should check the patient's pulse...if the pulse is absent, start CPR." This policy was not followed. An example includes:

Patient #32 was a 69 year old female admitted 11/23/20 with diagnoses of weakness and COVID-19. She died on 12/07/20.

Patient #32's record included a POST form dated 11/26/20. The form stated Patient #32 was a full code but did not want intubation, meaning if she was found without a pulse or not breathing, her wishes were that CPR would be initiated, but a breathing tube would not be placed.

Patient #32's record included a progress note, dated 11/26/20, signed by a physician. It stated, "CODE STATUS: Pt decided on 11/26 to be DNI but ok to do chest compressions."

Patient #32's record included a "HOSPITAL RESUSCITATION RECORD," dated 12/07/20, signed by the RN and the Emergency Physician. At 10:43, it stated, "called for code blue after pt. unresponsive, sternal rub." (In a hospital, a code blue means a cardiac or respiratory arrest.) At 10:50 PM, the record indicated 1 mg of epinephrine was given. There were no further resuscitative interventions listed on the resuscitation record. The record did not indicate whether Patient #32 had a pulse or was breathing. It stated the code blue was terminated at 10:52 PM, and the time of Patient #32's death was 10:52 PM.

Patient #32's record included a handwritten note, dated 12/07/20, signed by the Emergency Physician. It stated, "I was called to room for a code. On my arrival the pt. was pulseless, breathless, and unresponsive. The monitor showed asystole. She is pronounced deceased."

The assignment sheet from the evening shift of 12/07/20 was reviewed. It showed the RN caring for Patient #32 started her shift with 4 patients, two of them being COVID-19 isolation patients. It showed the RN received a new admission at 10:00 PM, 43 minutes before Patient #32 was found unresponsive. Additionally, it showed there was no CNA assigned to the unit.

According to the NCSBN Website's QuickConfirm License Verification Report, the RN had been licensed since August of 2020, giving her approximately 4 months of experience as a licensed RN as of 12/07/20.

The RN's personnel file was reviewed. There were no competencies in her personnel file. Competencies were requested but not provided prior to survey exit. It could not be determined the RN was trained how to initiate a code blue if a patient was found unresponsive.

The RN was interviewed by phone on 12/10/20 at 11:34 AM. When asked what Patient #32's code status was, the RN confirmed she was a full code DNI. When asked if staff performed CPR when she was found unresponsive, the RN stated, "we did not." When asked what interventions were done between 10:43 PM when the code was called and 10:52 PM when Patient #32 was pronounced deceased, the RN stated they tried to feel for a pulse and sternal rubbed her. When asked why CPR was not performed for her, the RN stated she was told in her report that if she did code, they probably would not do compressions because her airway was compromised. When asked if the decision not to do compressions was discussed with Patient #32, the RN stated it was not discussed because she was difficult to communicate with due to her BiPAP [bilevel positive airway pressure] oxygen mask.

The Charge Nurse who was working when Patient #32 died was interviewed by phone on 12/10/20 at 2:10 PM. The Charge Nurse stated she was ACLS certified, meaning she was trained to run a code blue. She stated she was aware the bedside RN called for the Emergency Physician to come to Patient #32's room. When asked if she entered Patient #32's room to assist during the code blue, she stated, "I never did go in the room." When asked why she did not go into Patient #32's room to help with the code blue as the ACLS certified RN on shift, the Charge Nurse stated, "I didn't realize there was a code." She also stated, "I gave them the epinephrine." According to Drugs.com, accessed 12/14/20, epinephrine is a drug that is "used for its alpha-adrenergic effects to increase blood flow and facilitate return of spontaneous circulation (ROSC) during cardiac arrest."

The Director of Nursing Services was interviewed on 12/10/20 at 1:23 PM. When asked if she would expect staff to perform CPR on a patient who was a full code DNI if they were found unresponsive she stated, "absolutely."

Emergency resuscitative efforts were not performed on a patient who was a full code DNI.

During the survey, Immediate Jeopardy was identified at 42 CFR 485.618 under the Condition of Participation: Emergency Services. The hospital was notified of the Immediate Jeopardy on 12/10/20 at 3:27 PM. A plan of correction for removal of the Immediate Jeopardy was submitted and accepted on 12/11/20 at 9:25 AM. On-site verification of the plan's implementation was also completed on 12/11/20 at 9:25 AM, and the Immediate Jeopardy was removed.

2. Refer to C-886, as it relates to the hospital's failure to ensure all drugs and biologicals used in life-saving procedures were not expired and readily available for all patients receiving care in the hospital.

3. Refer to C-888, as it relates to the hospital's failure to ensure emergency medical equipment and supplies were maintained.

The cumulative effect of these systemic practices prevented the hospital from providing emergency care based upon patients' needs.

Based on observation and staff interview, it was determined the facility failed to ensure all drugs and biologicals used in potentially life-saving procedures were not expired and readily available for all patients receiving care in the facility. This had the potential for patients' health and safety to be compromised in the event of a medical emergency. Findings include:

1. A tour of the hospital and observation of the hospital's emergency response carts and supplies was conducted in the presence of the COO and an OR technician on 12/08/20, beginning at 1:31 PM.

a. The following emergency medications were expired in the hospital's OR anesthesia cart:

- 1 vial Etomidate, expired 10/2020

- 1 vial Esmolol, expired 11/2020

- 2 tablets Naproxen, expired 8/2020

- 1 vial Nalbuphine, expired 9/2020

- 1 vial Diphenhydramine, expired 10/2020

- 1 50 ml bag of normal saline and Precidex premixed with no date

- 1 vial Dilaudid, open without a date, expired 6/2020

- 1 cartridge Ventolin, open without a date, expired 12/2018

- 1 vial Vasopressin, expired 5/2018

- 2 1000 ml bags of Normal Saline, expired 3/2016 and 9/2020

- 4 Normal Saline flushes, expired 2016, 2016, 2019, 2019

- 4 vials Xylocaine, expired 2/2020, 5/2020, 5/2020, 10/2020

- 1 vial Sodium Bicarbonate, expired 2019

- 1 vial Magnesium Sulfate, expired 9/2020

- 1 box Acetylcysteine, expired 6/2020

- 5 Sodium Chloride vials, expired 4/2020

- 1 vial Flumazenil, expired 10/2019

- 1 vial Ketorolac, expired 2/2019

- 4 vials Atropine, expired 11/2018

- 3 vials of Epinephrine, expired 11/2018, 6/2019, 11/2019

- 1 box of Glucagon, expired 12/2018

- 1 vial of Glycopyrolate, expired 1/2019

- 1 vial of Metoprolol, expired 8/2019

- 1 vial of Naloxone, expired 1/2020

- 1 50 ml bag of normal saline, expired 3/2016

- 1 1000 ml bag of Lactated ringers, expired 3/2016.

b. The following emergency medications were expired in the hospital's Malignant Hyperthermia cart

- 6 boxes of Dantrolene, expired 5/2020

- 1 box of Sodium Bicarbonate, expired 5/2019

- 1 box of Dextrose 50%, expired 5/2019

The COO was interviewed during the observations and tour of the OR on 12/08/20 beginning at 1:31 PM, and she confirmed the emergency medications were expired.

The Director of Pharmacy was interviewed on 12/10/20, beginning at 10:45 AM. When asked if he provided oversight of medications used in the hospital's anesthesia cart, he stated, "no" and "I'm responsible for the medications in the anesthesia cart." The Director of Pharmacy confirmed the hospital did not have an active policy regarding medication oversight, but stated a newly created policy was in the final stages of approval.

2. A tour of the hospital and observation of the hospital's emergency response carts and supplies was conducted in the presence of the DNS on 12/08/20, beginning at 9:00 AM.

a. The following emergency medications were expired in the Medical Surgical unit's emergency supply cart:

- 3 vials of Etomidate, expired 10/2020

- 6 normal saline flush syringes, expired 5/2018

- 1 50 ml bag of normal saline, expired 10/2020

b. The following emergency medications were expired in the Medical Surgical unit's intubation box:

- 2 vials of Propofol, expired 2/2020

- 2 250 ml bags of normal saline, expired 4/2020

- 2 vials of sterile water, expired 3/2019

- 2 vials of Etomidate, expired 6/2019

- 2 vials of vecuronium, expired 10/2019

c. The following medications were expired in the Emergency Department:

- 6 250 ml bags of normal saline, expiration dates ranging from 7/2018 through 4/2020

- 1 bottle of skin integrity wound cleanser, expired 6/2020

- 6 bottles of Iodine paint, expiration dates ranged from 7/2019 through 9/2020

The DNS was interviewed during the observations and tour of the multiple departments on 12/08/20 beginning at 9:00 AM, and she confirmed the emergency equipment was expired.

The hospital failed ensure all drugs and biologicals used in potentially life-saving procedures were not expired and readily available for all patients receiving care in the facility.

Based on observation, medical record review, and staff interview, it was determined the hospital failed to ensure emergency medical equipment and supplies were maintained. This resulted in irretrievable critical data for 1 of 1 inpatients (Patient #32) who had a cardiopulmonary arrest and died, and whose record was reviewed. Additionally, this had the potential for the health and safety of all inpatients and outpatients of the hospital to be compromised in the event of a medical emergency. Findings include:

1. Cardiac monitors were not maintained.

Patient #32 was a 69 year old female admitted 11/23/20, with diagnoses of weakness and COVID-19. She died on 12/07/20.

Patient #32's record included a POST form dated 11/26/20. The form stated Patient #32 was a full code, but did not want intubation, meaning if Patient #32 was found without a pulse or not breathing, her wishes were that CPR would be initiated, but a breathing tube would not be placed.

Patient #32's record included a progress note, dated 11/26/20, signed by a physician. It stated, "CODE STATUS: Pt decided on 11/26 to be DNI but ok to do chest compressions."

Patient #32's record included a "HOSPITAL RESUSCITATION RECORD," dated 12/07/20, signed by the RN and the Emergency Physician. At 10:43, it stated, "called for code blue after pt. unresponsive, sternal rub." (In a hospital, a code blue means a cardiac or respiratory arrest.) At 10:50 PM, the record indicated 1 mg of epinephrine was given. There were no further resuscitative interventions listed on the resuscitation record. The record did not indicate whether Patient #32 had a pulse or was breathing. It stated the code blue was terminated at 10:52 PM, and the time of Patient #32's death was 10:52 PM.

Patient #32's record included a handwritten note, dated 12/07/20, signed by the Emergency Physician. It stated, "I was called to room for a code. On my arrival the pt. was pulseless, breathless, and unresponsive. The monitor showed asystole. She is pronounced deceased."

The RN did not document the time Patient #32 became pulseless. Patient #32's medical record did not include data from her room's hardwired cardiac monitor. Additionally, without cardiac monitor records, Patient #32's cardiac status was unclear prior to her code blue.

Cardiac monitor records for Patient #32 were requested from the CEO on 12/10/20, at 4:05 PM.

The CEO was interviewed on 12/11/20, beginning at 8:17 AM. She stated Patient #32's cardiac monitor had failed and they were unable to retrieve cardiac monitor records. The CEO stated their IT department was notified to diagnose why the records could not be retrieved. She confirmed there was no cardiac monitor record of when Patient #32 became pulseless.

Cardiac monitors were not maintained.

2. A tour of the hospital and observation of the hospital's emergency response carts and supplies was conducted in the presence of the DNS on 12/08/20, beginning at 9:00 AM.

a. The following emergency supplies were expired in the Medical Surgical unit's emergency supply cart:

- 13 Magellan safety needles, expired 11/2019. This was the total number of safety needles in the emergency cart.

- 11 nasopharyngeal airways with expiration dates ranging from 2012 through 2016. This was the total number of nasopharyngeal airways in the emergency cart

- 10 arterial blood sampling kits, expired 5/2018. This was the total number of arterial blood sampling kits in the emergency cart.

- 3 LMA (a medical device that keeps a patient's airway open during anesthesia or unconsciousness), expiration dates ranging from 2015 to 2016. This was the total number of LMA's in the emergency cart.

- 1 Carbon dioxide detector, expired 2016.

- 1 Tracheal tube (used for intubation) expired 5/2011.

b. The following supplies were expired in the Medical Surgical unit's dedicated intubation box:

- 2 CO2 detectors, expired 2/2019.

- 2 nasotracheal cuffs, expired 3/2020.

c. The following supplies were expired in the Medical Surgical unit's OB hemorrhage cart

- 2 packages of vaginal swabs, expired 12/2017.

- 1 sterile speculum, expired 2/2020.

- 1 urinary catheter, expired 3/2010.

- 1 Foley catheter start kit tray, expired 8/2019.

d. The following supplies were expired the hospitals' Emergency Department:

- Emergency chest decompression kit (A kit including multiple supplies). The supplies in the kit had expiration dates ranging from 2017 through 2019.

- 1 Pericardiocentesis kit, expired 2010.

- 2 chest drain valves, expired 1/2020.

- 3 Iodiform strips, expired 2/2020, 2/2020, 10/2020.

- 1 Pneumothorax kit, expired on 7/2020.

- 4 Tegaderm, expired 6/2019.

- 3 Petrolatum gauze, expired 2/2019.

- 3 Silvasorb gel, expired 5/2020, 6/2020, 6/2020.

- 11 Xeroform gauze, expired 8/2020.

- 3 Penrose drains, expired 11/2019.

- 2 Mepilex, expired 10/2020.

- 8 Duoderm, expired 3/2018.

- 2 Non-adherent strips, expired 2/2020.

- 2 Foley catheters, expired 12/2019

e. The following supplies were expired in the hospital's difficult airway emergency cart:

- 1 King intubation kit, expired 12/2019.

- 4 stylets expired, 5/2015.

- 1 Intubation catheter, expired 10/2019.

- 1 Emergency cricothyrotomy kit, expired 9/2018.

- 1 Cricoid tray, expired 6/2017.

- 1 LMA, expired 6/2019.

- 1 Supraglottic airway, expired 12/2013.

- 4 stylets, expired 2/2020.

- 1 Jet insufflation cricothyrotomy kit, expired 9/2018

f. The following supplies were expired in the hospital's pediatric emergency crash cart and pediatric intubation box:

- 2 LMA's, expired 6/2020 and 10/2020.

- 1 NT tube, expired 10/2020.

- 3 end tidal CO2 detectors, expired 7/2020.

The DNS was interviewed during the observations and tour of the multiple departments on 12/08/20 beginning at 9:00 AM, and she confirmed the emergency supplies were expired.

3. A tour of the hospital and observation of the hospital's emergency response carts an supplies was conducted in the presence of the COO and an OR technician on 12/8/20, beginning at 1:31 PM.

The following supplies were expired in the hospital's OR anesthesia cart:

- 8 IV catheters, expired from 2014 to 2020.

- 3 IV start-kits, expired 2017, 2017, and 8/2020.

- 4 IV administration needles, expired 2/2018,

- 2 transparent dressings, expired 2015.

- 1 Minibore set, expired 3/2020.

- 3 Epidural needles, expired 8/2016, 5/2018, and 1/2020.

- 3 claves, expired 2017, 2017, and 2019.

- 1 Pneumothorax kit, expired 2014.

The COO was interviewed during the observations and tour of the OR on 12/08/20 beginning at 1:31 PM, and she confirmed the emergency supplies were expired.

The COO was interviewed on 12/10/20, beginning at 3:11 PM. When asked about oversite of hospital supplies, She confirmed oversight of the hospital's Central Supply system was not performed.

The facility failed to ensure medical supplies were maintained.



37262

Based on observation, medical record review, policy review, staff as-worked schedule review, personnel file review, RN licensure review, annual program evaluation review, patient rights information review, CDC infection control guidelines review, controlled substance record review, CMS form review, quality improvement plan review, and staff interview, it was determined the hospital's organizational structure was insufficient to ensure vital programs were defined, directed, and maintained. This resulted in a lack of leadership and direction to hospital staff. Findings include:

1. Refer to C-880, Condition of Participation: Emergency Services, and associated standard level deficiencies, as it relates to the hospital's failure to provide emergency care necessary to meet the needs of its inpatients and outpatients.

2. Refer to C-962, as it relates to the Governing Body's failure to ensure oversight of the hospital's operation and program, accountability of staff, and safe patient care were maintained.

3. Refer to C-1616, as it relates to the hospital's failure to evaluate and monitor medically-related social services to outpatients, inpatients, and swing-bed patients.

The cumulative effect of these systemic practices impeded the ability of the hospital to provide and document quality care.

Based on observation, annual program evaluation review, policy review, patient rights information review, CDC infection control guidelines review, controlled substances record review, and staff interview, it was determined the Governing Body failed to maintain oversight of the hospital's operation and program to ensure accountability of staff and safe patient care. This resulted in the hospital's sole anesthesia cart not being maintained, missing social services policies and quality review, outdated medications and equipment, and lack of oversight of critical systems to ensure safe patient care. Findings include:

1. The Governing Body failed to ensure oversight of anesthesia services.

The hospital's operating room was observed in the presence of an OR Tech and COO on 12/08/20, beginning at 1:27 PM. During the observation, 1 of 1 anesthesia carts were inspected and the following issues were identified:

a. The OR Tech was able to maneuver the anesthesia cart to the entrance of the hospital's sole operating room. During this maneuver, she was able to open the anesthesia cart without entering a manual code or inserting a key, as it was not locked. The following unsecured controlled medications were identified in the anesthesia cart:

- Morphine, a DEA Schedule II medication.

- Dilaudid, a DEA Schedule II medication.

- Ketamine, a DEA Schedule III medication.

- Fentanyl, a DEA Schedule III medication.

- Versed, a DEA Schedule IV medication.

Controlled medications were not secured.

b. The CDC infection control guidelines website, accessed 12/14/20, stated, "How far in advance of administration may I prepare an injection? From an infection control perspective, the safest practice is to prepare an injection as close as possible to the time of administration to the patient. This is to prevent compromised sterility (i.e., microbial contamination or proliferation) or compromised physical and chemical stability (e.g., loss of potency, adsorption to the container) of the medication when it is transferred outside of its original container and stored for a period of time before administration." These guidelines were not followed. Examples include:

i. There was 1 opened syringe with an attached needle which had approximately 2.5 ml of clear liquid pre-drawn and a hand-written word, "Esmolol [used to treat/prevent hyperdynamic states during surgery]," written on it. There was no written patient information or what date the liquid was drawn. It could not be determined if the syringe had been used in a previous surgical case or was pre-drawn for a future surgical case.

ii. There was 1 opened, empty syringe with an attached needle which had an affixed, "Succinylcholine [a skeletal muscle relaxant for IV administration indicated as an adjunct to general anesthesia, to facilitate tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation]" sticker. There was no written patient information or date. It could not be determined if the syringe had been used in a previous case or would be used in a future surgical case.

iii. There were 6 opened, empty syringes with attached needles. It could not be determined if the syringes had been used in a previous case or would be used in a future surgical case.

CDC infection control guidelines were not followed.

c. Inside the anesthesia cart was a form titled, "Controlled Substances Administration Record" which included sections for dates, times, patient names, physician names, names of controlled substances administered, staff signatures, and staff countersignatures. The form was incomplete. Examples include:

i. Medication administration times were not documented.

ii. 10/21/20 - Physician name for administered controlled substances was not documented.

iii. 10/28/20 - Staff countersignature for administered controlled substances was not documented and there was no end-of-day controlled substance count.

iv. 11/03/20 - Staff countersignature for administered controlled substances was not documented.

v. 11/10/20 - Staff countersignature for administered controlled substances was not documented and there was no end-of-day controlled substance count.

vi. 12/07/20 - Physician name for administered controlled substances was not documented, staff countersignature for administered controlled substances was not documented, and there was no end-of-day controlled substance count.

Controlled medication administration was not accurately documented.

d. There were 2 bags of candy found inside the anesthesia cart.

The COO was interviewed during the OR observation on 12/08/20, beginning at 1:27 PM. She confirmed the anesthesia cart should always be locked and secure. The COO stated the hospital's OR followed CDC guidelines for infection control and confirmed these guidelines were not followed. She confirmed medication syringes should never be opened ahead of time, nor should they contain pre-drawn medications. The COO stated there were no surgical cases scheduled for the week of survey and she was unsure how long the exposed syringes had been there. She confirmed the controlled substances administration record was incomplete. The COO confirmed food should not be stored inside the anesthesia cart. She stated oversight of the anesthesia cart was done by the CRNA's and the hospital did not play a part in that oversight.

A CRNA, who last provided anesthesia services in the hospital's OR on 12/07/20, was interviewed on 12/10/20, beginning at 9:30 AM. She stated she was a contracted CRNA with the hospital and had worked there since 2001. When presented with the hospital's anesthesia cart observations, the CRNA stated, "we've gotten behind" and "we were responsible." She stated she did not know where the pre-drawn medication syringe came from and confirmed it was not appropriate. When asked if the hospital's pharmacist provided input or oversight of medications stored in the anesthesia cart, the CRNA stated, "no, pharmacy is not involved in oversight." The CRNA stated the food in the anesthesia cart was not hers, but confirmed it should not have been there. Additionally, the CRNA confirmed the anesthesia cart's "Controlled Substances Administration Record" was incomplete. The CRNA stated she shared responsibility with maintaining the anesthesia cart with a hospital-employed CRNA.

The hospital-employed CRNA was not available for interview.

The Director of Pharmacy was interviewed on 12/10/20, beginning at 10:45 AM. When asked if he provided oversight of medications used in the hospital's anesthesia cart, he stated, "no" and "I'm responsible for the medications in the anesthesia cart." The Director of Pharmacy confirmed the hospital did not have an active policy regarding medication oversight, but stated a newly created policy was in the final stages of approval.

The Governing Body failed to ensure oversight of anesthesia services.

2. The Governing Body failed to ensure the hospital's annual program evaluation was followed and complete. Examples include:

a. The hospital's annual program evaluation, from Jan 2019 to Dec 2019, was reviewed. The evaluation listed 20 service lines which were evaluated:

- OPO
- Patient Days
- ADC
- Surgeries
- Deliveries
- ER Visits
- Outpatient Visits
- Laboratory Visits
- Radiology
- EKG
- Physical Therapy
- Occupational Therapy
- Pulmonary Therapy
- OP Treatment Room
- Respiratory Therapy
- Cardiac Rehab
- VNS
- Dietary
- Clinic Visits
- Provider Only Visits

i. The evaluation did not include a review of the hospital's central supply services. It could not be determined if the hospital evaluated how supplies and equipment were monitored to ensure expired items were not involved in patient care.

ii. The evaluation did not include medically-related social services. It could not be determined if medically-related social services were provided to outpatients, inpatients, or swing-bed patients.

Refer to C-1616, as it relates to the hospital's failure to evaluate services provided by medically-related social services and did not have policies which governed medically-related social services for outpatients, inpatients, or swing-bed patients.

b. The hospital's annual program evaluation stated, "EMERGENCY DEPARTMENT...Quality Assurance Review ...ER Crash Cart check monthly." Additionally, the evaluation stated, "ACUTE/SWING BED...Quality Control...Crash Cart Checks Monthly." This evaluation was not followed.

Refer to C-888, as it relates to the hospital's failure to ensure emergency medical equipment was maintained.

c. The hospital's annual program evaluation stated, "EMERGENCY DEPARTMENT...CLINICAL RECORDS...Deaths in the ED." This evaluation was not followed.

d. The hospital's annual program evaluation did not include death record reviews for inpatients. It was unclear if inpatient deaths were reviewed to ensure care was provided safely and effectively.

The Director of Quality was interviewed on 12/10/20, beginning at 8:00 AM, and the hospital's annual program evaluation was reviewed in her presence. She confirmed the evaluation was not followed for crash cart checks. Additionally, the Director of Quality confirmed the hospital's central supply and medically-related social services were not evaluated. She confirmed the hospital had not performed ED or inpatient death record reviews.

The Governing Body failed to ensure the hospital's annual program evaluation was followed and complete.

3. The Governing Body failed to execute their patient grievance policy.

A hospital policy, "Patient Grievance," reviewed 10/12/20, stated, "COMPLAINT & GRIEVANCE PROCESS...At the time of admission or presentation for care, each patient will be provided information regarding the process for registering a grievance or complaint. Included in this information will be the process for reporting complaint or grievances...To the CMS State enforcement agency." This policy was not followed.

A copy of patient rights information provided to outpatients and inpatients was reviewed. The information did not include the name, phone number, physical address, email address, or fax number of the Idaho Bureau of Facility Standards for the purpose of filing a patient complaint/grievance. It could not be determined how this information was provided to patients and/or their representatives.

The Director of Quality was interviewed on 12/10/20, beginning at 8:00 AM, and the hospital's grievance policy and patient rights information was reviewed in her presence. She confirmed patients and/or their representatives were not provided information for the Idaho Bureau of Facility Standards for the purpose of filing a complaint/grievance. The Director of Quality confirmed the hospital's policy was not followed.

The Governing Body failed to execute their patient grievance policy.

Based on CMS form review, annual program evaluation review, policy table of contents review, quality improvement plan review, and staff interview, it was determined the hospital failed to evaluate and monitor medically-related social services to outpatients, inpatients, and swing-bed patients. This had the potential for missed psychosocial interventions for all patients who required social services at the hospital. Findings include:

The hospital's CMS SOM Exhibit 286 for the year 2020 was reviewed and stated the hospital employed 1 Social Worker.

The hospital did not evaluate services provided by medically-related social services and did not have policies which governed medically-related social services for outpatients, inpatients, or swing-bed patients. Examples include:

1. The hospital's annual program evaluation, from Jan 2019 to Dec 2019, was reviewed. The evaluation listed 20 service lines which were evaluated:

- OPO
- Patient Days
- ADC
- Surgeries
- Deliveries
- ER Visits
- Outpatient Visits
- Laboratory Visits
- Radiology
- EKG
- Physical Therapy
- Occupational Therapy
- Pulmonary Therapy
- OP Treatment Room
- Respiratory Therapy
- Cardiac Rehab
- VNS
- Dietary
- Clinic Visits
- Provider Only Visits

The annual program evaluation did not include medically-related social services. It could not be determined if medically-related social services were provided to outpatients, inpatients, or swing-bed patients.

2. The hospital's quality improvement plan, dated 2020, was reviewed. The plan did not include medically-related social services. It could not be determined if medically-related social services were provided to outpatients, inpatients, or swing-bed patients.

3. The hospital's policy table of contents were reviewed and did not include medically-related social services policies. It could not be determined if, or how, medically-related social services were provided to outpatients, inpatients, or swing-bed patients.

Medically-related social services policies were requested from the COO on 12/08/20, at 2:57 PM and 12/09/20, at 9:23 AM. Requested policies were not provided by survey exit.

The COO was interviewed on 12/08/20, beginning at 1:47 PM. When asked if the hospital utilized medically-related social services, she stated yes and they were provided in the hospital's outpatient clinics. She stated, "we've never had social work in the hospital."

The Director of Quality was interviewed on 12/10/20, beginning at 8:00 AM, and the hospital's annual program evaluation, quality plan, and policy table of contents were reviewed in her presence. She confirmed the 3 documents did not include medically-related social services.

The hospital's 1 social worker, an LCSW, was interviewed on 12/10/20, beginning at 1:52 PM. She stated she had been an employee of the hospital for approximately 3 years. The LCSW stated she performed hospital inpatient consults upon provider request. She stated she primarily provided social services to outpatients who were seen in the hospital's clinics. When asked if she provided medically-related social services to swing-bed patients, she stated, "no." When asked if she sat on any hospital committees to report on outpatient or inpatient medically-related social services, the LCSW stated, "no." When asked if she participated in the hospital's quality program, she stated, "no."

The hospital did not evaluate services provided by medically-related social services and did not have policies which governed medically-related social services for outpatients, inpatients, or swing-bed patients.