HospitalInspections.org

Based on observation, staff interview, Idaho Board of Nursing Rules Review, website review, infection control guidelines review, medical record review, facility document review, personnel file review, and hospital policy review, it was determined the hospital failed to ensure the Governing Body was effective and assumed responsibility for the overall care of patients in the hospital ED and HOPDs. This resulted in the inability of the Governing Body to direct staff in the provision of patient care, and had the potential to impact all patients who received care at the hospital and its offsite locations. Findings include:

1. Refer to A - 0747 and its corresponding standard level deficiencies as it relates to the hospital's failure to ensure the hospital and HOPDs followed established infection control guidelines.

2. Refer to A - 1076 and its corresponding standard level deficiencies as it relates to the hospital's failure to maintain operational oversight of its outpatient locations and the care provided.

3. Refer to A - 1100 as it relates to the hospital's failure to ensure emergency services were provided in a safe and effective manner.

The facility was notified of an immediate jeopardy for failure to provide adequate emergency services at A - 1100 on 12/01/22 at 12:00 PM. A plan of correction was submitted and accepted on 12/01/22 at 4:40 PM, which stated, "The MVH Emergency Services department will close immediately, effective 02DEC2022 @ 0800 AM. All Emergency signs/signage will be removed/ or covered. Immediate steps will be taken to train all staff that the Mountain View Hospital does not currently have an Emergency Room. Frontline staff will be instructed to tell the public Mountain View Hospital does not currently have an Emergency Room and all persons seeking Emergency Room Services will be directed to Idaho Falls Community Hospital's Emergency Room."

On-site verification of the plan's implementation was completed on 12/02/22 at 9:50 AM, and the immediate jeopardy was removed.

The cumulative effect of these systemic practices resulted in the inability of the hospital to meet the needs of patients.




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Based on observation, medical record review, Idaho Board of Nursing Rules Review, hospital policy, hospital documentation, personnel file review, infection control guidelines review, and staff interview, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in care not being provided in a safe setting and had the potential to affect all patients receiving care at the hospital. Findings include:

1. Refer to A - 0144, as it relates to the failure of the hospital to ensure care was provided in a safe setting.

Based on observation, record review, policy review, Idaho Board of Nursing Rules Review, personnel file review, website review, infection control guidelines review, and staff interview, it was determined the hospital failed to provide care in a safe setting for 10 of 42 (Patients #6, #7, #8, #9, #10, #13, #14, #15, #16, and #42) patients whose records were reviewed, 1 of 1 patient (Patient #1) whose procedure was observed, and for 2 of 4 HOPDs that were observed. This put all patients, including outpatients, receiving hospital services at risk of negative outcomes. Findings include:

1. The hospital failed to ensure IV medications were given by licensed staff.

A facility policy titled, "IV Therapy: Peripheral IV Line," revised 11/2022, stated, "The state of Idaho allows other personnel, other than licensed personnel, to start PIVs, if the facility they work in allows it and there is proof of education and training. Mountain View Hospital allows clinical employees, other than RNs or LPNs to start PIVs after they have completed the required training which consists of an online course and the completion of ten IV starts witnessed by a licensed employee."

A facility policy titled, "Medication Administration," revised 1/2022, stated, "In the instance of intravenous therapy ... only those persons trained, with competency proved by the facility will be allowed to administer such medications, in accordance with state law."

Idaho Board of Nursing Rules 24.34.01, accessed 12/07/22, stated the following, "UAPs may complement the licensed nurse in the performance of nursing functions, but cannot substitute for the licensed nurse." The rules also stated, "UAPs in care settings may assist patients who cannot independently self-administer medications ... Assistance with medication may include: breaking a scored tablet, crushing a tablet, instilling eye, ear or nose drops, giving medication through a pre-mixed nebulizer inhaler or gastric (non-nasogastric) tube, assisting with oral or topical medications and insertion of suppositories." The rules did not speak to delegation of IV line insertion and IV therapy to UAP.

According to the AAMA website, accessed 12/07/22, CMAs are credentialed (https://www.aama-ntl.org/medical-assisting/what-is-a-cma). In the state of Idaho, MAs and CMAs do not hold a license.

Patient #42 was a 23 year old pregnant female who was seen in an HOPD urgent care clinic on 7/07/22 for treatment of nausea and vomiting. Her record included documentation that at 4:46 PM, a PIV line was started by an MA. Patient #42 received 1 liter of normal saline through her PIV line, administered by the MA.

According to RXlist.com, accessed 12/07/22, "Normal Saline is a prescription medicine used for fluid and electrolyte replenishment for intravenous administration." (https://www.rxlist.com/normal-saline-drug.htm)

The personnel file for the MA who provided care for Patient #42 was reviewed. Competencies for her IV technique were requested in person from the VP of Clinical Services for the urgent care on 12/02/22. Her IV certification from an educational institution was provided but no competencies were provided. An additional telephone call to request the MA's competencies was placed on 12/06/22, 2 business days after survey exit. No call back was received and no competencies were provided.

The Urgent Care DCS and VP of Clinical Services were interviewed together on 12/02/22 beginning at 8:45 AM, and Patient #42's record was reviewed in their presence. The VP of Clinical Services stated MAs could not give IV medication, but they could give IV saline if they were IV certified. She stated MAs could start an IV if they were certified.

The facility failed to ensure IV medications were administered in accordance with state law and applicable policy and procedures.

2. The facility failed to maintain a sanitary environment.

a. An offsite doctor's clinic and urgent care was toured on 11/29/22 beginning at 11:00 AM. The tour was conducted with the Practice Manager and an MA. An observation of the room where instruments were cleaned and sterilized was conducted with the MA during the tour. During the observation there was an approximately 2-gallon white bucket in a sink. The bucket contained a green solution. The bucket also contained several instruments that were used on patients, waiting to be sterilized. The bucket was not labeled. When asked what the solution was, the MA stated it was the instrument enzymatic cleaner and water. When asked how long the instruments had been in the bucket with the enzymatic solution the MA was unsure. The MA provided the enzymatic cleaner named "Medline single enzymatic detergent and presoak." The enzymatic cleaner had the following IFU:

- Use with a water temperature between 90 and 110 degrees
- Mix fresh solution immediately prior to use
- mix 1 ounce enzymatic per 1 gallon of water
- Change solution after every scope or batch of soiled items

These IFU were not followed. Examples include:

During the above observation the MA was interviewed on how the instruments were cleaned prior to sterilization. The MA stated at the beginning of the week the 2 gallon bucket was filled with approximately 50/50 mixture of enzymatic cleaner and water. She stated the bucket had no measurement lines to indicate how much of water or enzymatic was used. After review of the IFU for the enzymatic solution listed on the bottle, she confirmed the ratio should have been 1 ounce enzymatic cleaner to 1 gallon of water.

When asked if there was any temperature monitoring done for the water used with the enzymatic cleaner she said no. She confirmed the water temperature should have been monitored.

When asked if fresh solution was mixed after every soiled batch of instruments she said no, the enzymatic cleaner and water was emptied at the end of the week. She confirmed after reviewing the IFU it should have been changed after every soiled batch of instruments and immediately prior to use on instruments.

b. A facility policy titled "Infection Prevention and Control Program" dated 6/2021 stated, "Mountain View Hospital's infection prevention and control program shall be conducted in accordance with all applicable federal and state rules and regulations, accrediting body standards, as well as nationally recognized infection prevention and control practices and guidelines including evidence based guidelines and recommendations from the following organizations ... Centers for Disease control and prevention (CDC)."

CDC guidelines for disinfection and sterilization in healthcare facilities were reviewed, accessed 12/05/22 (https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html). The guidelines stated, "Cleaning is the removal of foreign material (e.g., soil, and organic material) from objects and is normally accomplished using water with detergents or enzymatic products. Thorough cleaning is required before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes. Also, if soiled materials dry or bake onto the instruments, the removal process becomes more difficult and the disinfection or sterilization process less effective or ineffective. Surgical instruments should be presoaked or rinsed to prevent drying of blood and to soften or remove blood from the instruments." These guidelines were not followed. An example includes:

A tour of an off-site doctor's office and urgent care was conducted on 12/01/22 beginning at 2:27 PM. The tour was conducted with the Practice Manager and an RN. In one of the patient rooms was a plastic container with approximately 20 used instruments in it. Approximately 10 of the 20 instruments had dried blood on them. The RN was asked about the dirty instruments. She stated she did not know how long they had been in the plastic container. She stated the instruments were cleaned and sterilized at the end of the week.

An interview was conducted with the Practice Manager and the VP of Clinical Services on 12/02/22 beginning at 9:00 AM. The VP of Clinical Services confirmed the instruments should have been kept moist or presoaked and should not have been allowed to dry with blood prior to cleaning based on CDC guidelines.

c. A facility policy titled, "Hand Hygiene-CDC Guidelines" dated 6/2021, stated "The CDC has recommended guidelines on when to use non-antimicrobial soap and water, an antimicrobial soap and water or an alcohol-based hand rub ... After coming in contact with patient's intact skin, i.e., taking a patient's blood pressure, pulse, lifting/moving the patient ... After contact with medical equipment/supplies in patient areas." This policy was not followed. An example includes:

On 11/29/22 beginning at 11:15 AM, a tour of the MVH Endoscopy center was conducted and Patient #1's upper endoscopy procedure was observed. Patient #1 was a 38 year old female scheduled for an upper endoscopy for reflux. Patient #1 was observed from admission until completion of procedure. The Anesthesiologist in the procedure room was observed wearing gloves. He inserted medications into Patient #1's IV, touched the side rail, charted on his bedside computer, then dropped a syringe with white medication on the floor. He picked up the syringe from the floor and then discarded the syringe. Throughout the above observations the Anesthesiologist did not remove gloves or perform hand hygiene. At the end of the procedure, the Anesthesiologist pushed Patient #1 out of the GI Lab on the stretcher, wearing the same gloves. He touched the GI Lab door with contaminated gloves.

On 11/29/22 beginning at 11:30 AM , the Endoscopy Manager was interviewed and she confirmed the Anesthesiologist should have performed hand hygiene and replaced his gloves.

The hospital failed to maintain a sanitary environment.

3. The hospital failed to provide adequate ED services

a. The facility failed to ensure staff were trained to work in the ED.

The MVH ED opened on 9/30/22. A policy dated 11/2022 and titled, "MVH Emergency Services: Staff Orientation" stated, "Emergency Services orientation shall include, but not be limited to:
a. General orientation to MVH Emergency Services
b. Introduction to the MVH Emergency Services policy and procedure manual
c. Introduction to nurses' documentation forms
d. Introduction to MVH Emergency Services forms
e. Introduction to MVH Emergency Services equipment
f. Safety Manual
g. Fire and Emergency Management manuals
h. Emergency Services-specific security measures in place
i. Admission of patients to MVH Emergency Services
j. Discharge of patients from MVH Emergency Services
k. Criteria to identify potential abuse victims and potential abusers
l. Provider referrals
m. Transfer procedures to outside facility following HIIPA [sic] guidelens [sic]
n. Crash cart
o. Skills Checklist"

This policy was not followed. Examples include:

On 11/30/22 beginning at 3:35 PM, the DON and the Medical Surgical Manager were interviewed and ED competencies were requested for staff who worked in the ED. No competencies were provided that were specific to the ED. The Medical Surgical Manager was asked if there were any competencies, code blue drills, or specific emergency training done in the ED. The Medical Surgical Manager stated no mock codes were done and, "we are working on competencies for the ED."

On 12/01/22 beginning at 11:15 AM, the Medical Surgical Charge RN who also covered the ED was interviewed and asked what training was provided in the ED. He stated the training consisted of a tour of the ED and the location of forms and paperwork.

The facility failed to provide adequate emergency training per facility policy.

b. The hospital's ED did not have dedicated staff.

On 11/30/22 beginning at 3:35 PM, the DON and the Medical Surgical Manager were interviewed. Surveyors requested an ED staff schedule. When asked how staffing worked in the ED, the Medical Surgical Manager stated there was not a dedicated ED staff schedule. She stated the Charge RN who was working on the Medical Surgical floor would get an alert from communications to go to the ED to meet the patient. Both were asked if staff were physically present in the ED at the time of the interview, they said, "no."

MVH shared a building with a hospital called IFCH. MVH was on one side of the building and IFCH was on the other side of the same building. They shared a common main entrance. A physician coverage schedule for MVH's ED was provided. It listed one ED physician as sole coverage 24/7 from 10/01/22 to current. Additionally, it had documented the ED Physician was also scheduled at IFCH's ED. Of the 61 days from 10/01/22 through 11/30/22, the ED physician was scheduled at both ED's 25 times. It was unclear how the physician would provide emergency coverage in both EDs at the same time.

The ED Physician was interviewed 11/30/22 beginning at 2:00 PM. When asked who provided coverage for MVH ED he stated he was the sole for the MVH ED. He stated the hospital was working on completing a contract with a physicians group to provide more coverage. When asked if he physically saw patients in the MVH ED, he stated he tries to see the patients at MVH. He stated if he was working in IFCH while covering MVH, he would have the patient transferred to IFCH because more services are provided at IFCH. He stated he was the transferring and accepting physician when he covered both ED's.

The facility failed to provide dedicated ED staff.

c. There was no documentation of stabilizing treatment, diagnostic testing, or assessment by a physician prior to transfer in 9 of 11 patients (Patients #6, #7, #8, #9, #10, #13, #14, #15, and #16 ) whose ED records were reviewed.

i. Patient #7 was a 59 year old female who presented to the ED on 11/22/22 at 5:50 PM with a chief complaint of "blood in stool."

Patient #7's medical record included a history of stroke and gastric bypass. Patient #7"s medical record included a pain rating of 9 out of 10 in her knee and abdomen, with 10 being the worst pain. Patient #7's vital signs were taken. There was no documentation throughout Patient #7's record of diagnostics or treatment provided.

Patient #7's medical record included a note by an RN dated 11/22/22 at 6:08 PM. It stated "Pt came to MVH ER complaining of blood in the stool and pain in her knee and abdomen. Pt explained history of stroke, gastric bypass and total knee surgery."

The next note in Patient #7's record dated 11/22/22 at 6:06 PM stated, "Called [ED MD on-call] and received verbal order to transfer patient to IFCH ER"

Patient #7's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer. When asked if the ED Physician assessed Patient #7 prior to her transfer, she stated there was no documentation.

ii. Patient #8 was a 72 year old male who presented to the ED on 11/20/22 at 8:32 AM with a chief complaint of "pain in legs."

Patient #8's record included a nurse's note at 8:37 AM which stated, "pt reported with fluctuating leg pain up to 10/10. I did a head to toe assessment and called [ED MD on-call]. He gave a verbal to transfer to IFCH ER." The nursing assessment stated, "irregular heartbeat ... BLE weakness." The record stated Patient #8's medical history included "cardiac ablations x2, PE, DVT, BLE edema, irregular heartbeat." Patient #8's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for Patient #8.

The ED MD was interviewed on 11/30/22 beginning at 2:00 PM. Patient #8's chart was reviewed in his presence. When asked if he came to the ED to see Patient #8, he replied, "no, I directed them to send to IFCH ED and then I headed in." When ED MD was asked if this transfer to IFCH ED was different than a transfer to another hospital, he replied, "nope, I call and say they are coming."

iii. Patient #9 was a 62 year old male who presented to the ED on 11/16/22 at 12:59 PM with a chief complaint of "sent by [name] Medical Group for fall work up."

Patient #9's record included a nurse's note, not timed, which stated, "Pt was supposed to report to IFCH ER but ended up at MV [Mountain View] ER. I called [name] PA and got a history on the patient and what orders he was wanting. I called [ED MD on-call] and orders were received to transfer to IFCH ER." There was no documentation Patient #9 was seen by a physician prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation to indicate patient #9 was seen or assessed by a physician prior to transfer.

iv. Patient #10 was an 81 year old male who presented to the ED on 11/02/22 at 7:49 AM with a chief complaint of "pain in left leg/thigh weakness."

Patient #10's medical record stated he refused vital signs. The nurse's note stated, "pt arrived with c/o pain in left leg and increase in swelling ... but never had pain [before]. Called [ED MD on-call] and discussed ... ordered to transfer to IFCH. Pt stated he wanted what was going to be the fastest and declined any more assessment with me and wanted to go to the ER." Patient #8's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer of Patient #10.

v. Patient #13 was a 63 year old female who presented to the ED on 11/01/22 at 5:33 PM with a chief complaint of shortness of breath.

Patient #13's record included the Emergency Care Record Assessment which stated, "difficulty swallowing and clearing food ... pain: headache shooting into back. pain...4/10; ... SpO2 [oxygen level] =87% on RA [room air] at 5:50 PM."

Patient #13's medical record did not include documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for Patient #13.

vi. Patient #14 was a 21 year old male who presented to the ED on 10/01/22 at 1:36 PM with a chief complaint of "cut on head from gun scope."

Patient #14's record included a nurse's note at 1:25 PM which stated: "V.O. [verbal order] Dr. [ED MD]. Transfer to IFCH ER."

Patient #14's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for Patient #14.

vii. Patient #15 was a 20 year old female employee of the hospital who presented to the ED on 11/15/22 at 11:12 AM with a chief complaint of "chest pain and SOB [shortness of breath]" while at work. A rapid response was called.

Patient #15's record did not include a nursing assessment. A physician note stated a call was received from the physician on the rapid response and Patient #15 would be transferred to IFCH ED, however Patient #15's record did not include assessment by an ED physician at MVH. Additionally, there was no time of arrival, vital signs, or disposition listed in the ED record.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or ED provider assessment prior to transfer for Patient #15.

viii. Patient #16 was a 57 year old female who presented to the ED on 10/23/22 at 12:35 PM with a chief complaint of "weakness."

Patient #16's medical record included the Emergency Care Record Assessment which stated, "Pt c/o [complains of] headache 5/10." A nurse's note stated, "Pt taken to IFCH ER per [ED MD] verbal order."

Patient #16's medical record did not include documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for Patient #16.

ix. Patient #6 was a 4 year old female who presented to the ED on 11/26/22 at 10:40 PM with a chief complaint of "left ear pain."

Patient #6's medical record included a nurse's note which stated, "[ED MD] notified, he instructed us to transfer patient to IFCH ER."

Patient #6's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for patient #6.

4. Incomplete documentation regarding patient transfers was found in 5 of 11 patients (Patients #8, #9, #10, #15, and #16) whose ED records were reviewed.

a. Patient #8 was a 72 year old male who presented to the ED on 11/20/22 at 8:32 AM with a chief complaint of "pain in legs."

Patient #8's transfer record was incomplete. The following sections were left blank:

- Accepting physician
- Time contacted
- Mode of transportation.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed Patient #8's emergency care and transfer records were incomplete.

b. Patient #9 was a 62 year old male who presented to the ED on 11/16/22 at 12:59 PM with a chief complaint of "sent by [name] Medical Group for fall work up."

Patient #9's medical record did not include a "Patient Transfer Record" form. A request for the Patient Transfer Record form was made on 12/01/22 at 1:45 PM. The transfer record was not provided prior to survey exit.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed Patient #9's record was incomplete.

c. Patient #10 was an 81 year old male who presented to the ED on 11/02/22 at 7:49 AM with a chief complaint of "pain in left leg/thigh weakness."

Patient #10's transfer record was incomplete. There was no accepting physician name or time documented. There was no documentation of a report called to accepting hospital.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed the transfer record for Patient #10 was incomplete.

d. Patient #15 was a 20 year old female employee of the hospital who presented to the ED on 11/15/22 at 11:12 AM complaining of chest pain and SOB while at work. A rapid response was called.

Patient #15's transfer record was incomplete. There was no accepting physician name or time documented There was no document of report called or time of transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed the transfer record for Patient #15 was incomplete.

e. Patient #16 was a 57 year old female who presented to the ED on 10/23/22 at 12:35 PM with a chief complaint of "weakness."

Patient #16's transfer record was incomplete. There was no name, title, or time of report called prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed the transfer record for Patient #16 was incomplete.

5. It was unable to be determined if all patients presenting to MVH ED were logged and seen by MVH staff.

On 11/29/22 beginning at 3:30 PM, the Quality Assurance Manager provided a tour of the ED and walked surveyors through the ED registration process. Two non-clinical front desk staff were stationed in the main entrance of the lobby in front of a wall with a directory. The wall was broken into two sections, one for Mountain View Hospital and one for Idaho Falls Community Hospital. The directory for MVH included "EMERGENCY" in white lettering. The directory for IFCH included "EMERGENCY" in red lettering. Front desk staff were asked which ED do patients with chest pain get directed to. Front desk staff stated, "anything with the heart goes to IFCH." The MVH Admissions Manager joined the interview at the front desk with surveyors. The Admissions Manager stated that patients decide which ED they want to go to, "it's patient's choice." The Admissions Manager was asked what the process was if a patient arrived with a medical emergency and unable to communicate. The Admissions Manager stated that staff would call a "Rapid Response or Code Blue." The Admissions Manager said if the patient is bleeding, has shortness of breath they would call the Rapid Response team, if patient has chest pain the Code Blue team would be called. A form titled, "MVH EMTALA" that is used by non-clinical front desk staff was provided and states:
"IMMIDIATELY [sic] CALL A RAPID RESPONSE IF PATIENT IS
-BLEEDING
-SHORTNESS OF BREATH
-IN IMMIDIATE [sic]/URGENT NEED OF CARE
IMMEDIATELY CALL A CODE BLUE IF THE PATIENT IS HAVING CHEST PAIN"

The Admissions Manager continued to walk surveyors through the process of an ED registration. An admissions person would, "walk or wheelchair" the patient to the MVH ED after notifying communications that a there is a patient that has arrived for the ED. Communications sends out a group text to the med-surg charge RN, admission staff, and ED MD. The Admissions Manager stated, "admission person stays with the patient until RN arrives" in the ED. Surveyor confirmed with Admissions Manager that admission staff have no medical licenses or training. No ED staff were present in the ED during this observation.

The Medical Surgical charge nurse who was covering the ED was interviewed 11/30/22 beginning at 2:27 PM. When asked what patients are treated in the MVH ED she stated anyone who needs minimal treatments, xrays, and sutures. When asked the process for a patient presenting with chest pain to the MVH ED, she stated she would immediately wheel the patient down to IFCH ED for the fastest treatment, and contact the MD when taking the patient across the hosptial.

It was unable to be determined if all patients presenting to MVH ED were logged and seen by MVH staff.

The facility was notified of an immediate jeopardy at Emergency Services tag 1100 on 12/01/22 at 12:00 PM. A plan of correction was submitted and accepted on 12/01/22 at 4:40 PM. The plan stated, "The MVH Emergency Services department will close immediately, effective 02DEC2022 @ 0800 AM. All Emergency signs/signage will be removed/ or covered. Immediate steps will be taken to train all staff that the Mountain View Hospital does not currently have an Emergency Room. Frontline staff will be instructed to tell the public Mountain View Hospital does not currently have an Emergency Room and all persons seeking Emergency Room Services will be directed to Idaho Falls Community Hospital's Emergency Room." On-site verification of the plan's implementation was completed on 12/02/22 at 9:50 AM and the immediate jeopardy was removed.

Based on record review, policy review, Idaho Board of Nursing Rules review, website review, personnel file review, and staff interview, it was determined the facility failed to ensure IV medications were administered in accordance with state law for 1 of 1 outpatients (Patient #42) whose record was reviewed and who received IV medication. This put all patients receiving IV medications at risk of complication by not being administered by a licensed nurse. Findings include:

A facility policy titled, "IV Therapy: Peripheral IV Line," revised 11/2022, stated, "The state of Idaho allows other personnel, other than licensed personnel, to start PIVs, if the facility they work in allows it and there is proof of education and training. Mountain View Hospital allows clinical employees, other than RNs or LPNs to start PIVs after they have completed the required training which consists of an online course and the completion of ten IV starts witnessed by a licensed employee."

A facility policy titled, "Medication Administration," revised 1/2022, stated, "In the instance of intravenous therapy ... only those persons trained, with competency proved by the facility will be allowed to administer such medications, in accordance with state law."

Idaho Board of Nursing Rules 24.34.01, accessed 12/07/22, stated the following, "UAPs may complement the licensed nurse in the performance of nursing functions, but cannot substitute for the licensed nurse." The rules also stated, "UAPs in care settings may assist patients who cannot independently self-administer medications ... Assistance with medication may include: breaking a scored tablet, crushing a tablet, instilling eye, ear or nose drops, giving medication through a pre-mixed nebulizer inhaler or gastric (non-nasogastric) tube, assisting with oral or topical medications and insertion of suppositories." The rules did not speak to delegation of IV insertion and IV therapy to UAP.

According to the AAMA website, accessed 12/07/22, CMAs are credentialed (https://www.aama-ntl.org/medical-assisting/what-is-a-cma). In the state of Idaho, MAs and CMAs do not hold a license.

Patient #42 was a 23 year old pregnant female who was seen in an HOPD urgent care clinic on 7/07/22 for treatment of nausea and vomiting. Her record included documentation that at 4:46 PM, a PIV line was started by a medical assistant. Patient #42 received 1 liter of normal saline through her PIV line, administered by the MA.

According to RXlist.com, accessed 12/07/22, "Normal Saline is a prescription medicine used for fluid and electrolyte replenishment for intravenous administration." (https://www.rxlist.com/normal-saline-drug.htm)

The MA's personnel file, who provided care for Patient #42 on 7/07/22, was reviewed. Competencies for her IV technique were requested in person from the VP of Clinical Services for the urgent care on 12/02/22. Her IV certification from an educational institution was provided but no on the job competencies from the HOPD were provided. An additional telephone call to request the MA's competencies was placed on 12/06/22, 2 business days after survey exit. No call back was received, and no competencies were provided.

The Urgent Care DCS and VP of Clinical Services were interviewed together on 12/02/22 beginning at 8:45 AM, and Patient #42's record was reviewed in their presence. The VP of Clinical Services stated MAs could not give medication, but they could give saline if they were IV certified. She stated MAs could start a PIV line if they were certified.

The facility failed to ensure IV medications were administered in accordance with state law and applicable policy and procedures.

Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure medical records were complete in 8 of 42 patients (Patients #8, #9, #10, #13, #15, #16, #38, and #39) whose records were reviewed. This resulted in incomplete documentation in medical records and had the potential to impact care delivery due to missing information. Findings include:

1. ED records were incomplete.

a. Patient #8 was a 72 year old male who presented to the ED on 11/20/22 at 8:32 AM with a chief complaint of "pain in legs."

Patient #8's emergency care record was incomplete. The following sections were left blank:

- Did an emergency medical condition exist?
- DC Condition
- DC Instructions
- Prescriptions
- Disposition

Patient #8's transfer record was incomplete. The following sections were left blank:

- Accepting physician
- Time contacted
- Mode of transportation.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed Patient #8's emergency care and transfer records were incomplete.

b. Patient #9 was a 62 year old male who presented to the ED on 11/16/22 at 12:59 PM with a chief complaint of "sent by [name] Medical Group for fall work up."

Patient #9's emergency care record was incomplete. The following sections were left blank:

- Did an emergency medical condition exist?
- DC Condition
- DC Instructions
- Prescriptions
- Disposition

Patient #9's medical record did not include a "Patient Transfer Record" form. A request for the Patient Transfer Record form was made on 12/01/22 at 1:45 PM. The transfer record was not provided prior to survey exit.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed Patient #9's record was incomplete.

c. Patient #10 was an 81 year old male who presented to the ED on 11/02/22 at 7:49 AM with a chief complaint of "pain in left leg/thigh weakness."

Patient #10's record was incomplete as follows:

- The DC condition stated stable for discharge. It also stated Patient #10 was transferred. It was unclear through documentation why Patient #10 was listed stable for discharge but was transferred.
- There was no time for when the administrator on-call was notified.
- There was no name or time listed for the accepting physician nor was there a name or time for "Report called to."
- The patient signature, date, and time for consent to transfer was blank.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed Patient #10's record was incomplete.

d. Patient #13 was a 63 year old female who presented to the ED on 11/01/22 at 5:33 PM with a chief complaint of "SOB."

Patient #13's mergency care record was incomplete. The following sections were left blank:

- Did an emergency medical condition exist?
- DC Condition
- DC Instructions
- Prescriptions
- Disposition

The DON was interviewed on 12/01/22 beginning at 10:30 AM. She confirmed Patient #13's record was incomplete.

e. Patient #15 was a 20 year old female employee of the hospital who presented to the ED on 11/15/22 at 11:12 AM complaining of chest pain and SOB while at work.

Patient #15's transfer record was incomplete as follows:

- There was no time for when the administrator on-call was notified.
- There was no name or time listed for the accepting physician.
- There was no name or time for "Report called to."

The DON was interviewed on 12/01/22 beginning at 10:30 AM. She confirmed Patient #15's record was incomplete.

f. Patient #16 was a 57 year old female who presented to the ED on 10/23/22 at 12:35 PM with a chief complaint of "weakness."

Patient #16's emergency care record was incomplete as follows:

- The DC condition stated stable for discharge. It also stated Patient #16 was transferred. It was unclear through documentation why Patient #16 was listed stable for discharge but was transferred.

Patient #16's transfer record was incomplete as follows:

- There was no name or time for "Report called to."

The DON was interviewed on 12/01/22 beginning at 10:30 AM. She confirmed Patient #16's record was incomplete.

2. Inpatient records were incomplete.

A hospital policy titled "Documentation and Handling of Incomplete and Delinquent Medical Records," stated, "Discharge summary: Completed the last day of service." This policy was not followed. Examples include:

a. Patient #38 was a 55 year old female admitted on 5/13/22 for surgery. Patient #38 was discharged on 5/16/22. There was no discharge summary in Patient #38's medical record.

Patient #38's medical record was reviewed with the Supervisor of Medical Records on 12/01/22 beginning at 4:00 PM. She was unable to provide a discharge summary. She confirmed the medical record was still incomplete after 5 months and the physician had been notified.

b. Patient #39 was a 28 year old female admimtted 7/14/22 for a Cesarean section. Patient #39 was discharged on 7/18/22. There was no discharge summary for Patient #39.

Patient #39's medical record was reviewed with the Supervisor of Medical Records on 12/01/22 beginning at 4:00 PM. She was unable to a discharge summary for patient #39.

The facility failed to ensure medical records were complete and accurate.

Based on observation, review of CDC guidelines, review of policies, facility document review, and staff interview, it was determined the hospital failed to provide a sanitary environment and promote safe practices to avoid sources and transmission of potential infection in 2 of 3 offsite locations toured, and for 1 of 2 patients, (Patient #1) whose care was observed in the hospital. This failure had the potential to affect all staff and patients working or receiving care in the facility. Failure to ensure proper infection control processes had the potential to impact the health of patients and staff. Findings include:

1. Refer to A - 0749 as it relates to the failure of the facility to maintain a sanitary environment for all patients receiving care in HOPDs and in the hospital.

Based on observation, review of CDC guidelines, facility document review, and staff interview, it was determined the facility failed to maintain a functional and sanitary environment for 1 of 2 patients (Patient #1) whose care was observed in the hospital and for 2 of 3 HOPDs that were inspected. This had the potential to put patients receiving care at the facility and at HOPD locations at an increased risk of infections. Findings include:

1. An offsite doctor's clinic and urgent care was toured on 11/29/22 beginning at 11:00 AM. The tour was conducted with the Practice Manager and an MA. An observation of the room where instruments were cleaned and sterilized was conducted with the MA during the tour. During the observation there was an approximately 2-gallon white bucket in a sink. The bucket contained a green solution. The bucket also contained several instruments that were used on patients, waiting to be sterilized. The bucket was not labeled. When asked what the solution was, the MA stated it was the instrument enzymatic cleaner and water. When asked how long the instruments had been in the bucket with the enzymatic solution the MA was unsure. The MA provided the enzymatic cleaner named "Medline single enzymatic detergent and presoak." The enzymatic cleaner had the following IFU:

- Use with a water temperature between 90 and 110 degrees
- Mix fresh solution immediately prior to use
- mix 1 ounce enzymatic per 1 gallon of water
- Change solution after every scope or batch of soiled items

These IFU were not followed. Examples include:

During the above observation the MA was interviewed on how the instruments were cleaned prior to sterilization. The MA stated at the beginning of the week the 2 gallon bucket was filled with approximately 50/50 mixture of enzymatic cleaner and water. She stated the bucket had no measurement lines to indicate how much of water or enzymatic was used. After review of the IFU for the enzymatic solution listed on the bottle, she confirmed the ratio should have been 1 ounce enzymatic cleaner to 1 gallon of water.

When asked if there was any temperature monitoring done for the water used with the enzymatic cleaner she said no. She confirmed the water temperature should have been monitored.

When asked if fresh solution was mixed after every soiled batch of instruments she said no, the enzymatic cleaner and water was emptied at the end of the week. She confirmed after reviewing the IFU it should have been changed after every soiled batch of instruments and immediately prior to use on instruments.

2. A facility policy titled "Infection Prevention and Control Program" dated 6/2021 stated, "Mountain View Hospital's infection prevention and control program shall be conducted in accordance with all applicable federal and state rules and regulations, accrediting body standards, as well as nationally recognized infection prevention and control practices and guidelines including evidence based guidelines and recommendations from the following organizations ... Centers for Disease control and prevention (CDC)."

CDC guidelines for disinfection and sterilization in healthcare facilities were reviewed, accessed 12/05/22 (https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html). The guidelines stated, "Cleaning is the removal of foreign material (e.g., soil, and organic material) from objects and is normally accomplished using water with detergents or enzymatic products. Thorough cleaning is required before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes. Also, if soiled materials dry or bake onto the instruments, the removal process becomes more difficult and the disinfection or sterilization process less effective or ineffective. Surgical instruments should be presoaked or rinsed to prevent drying of blood and to soften or remove blood from the instruments." These guidelines were not followed. An example includes:

A tour of an off-site doctor's office and urgent care was conducted on 12/01/22 beginning at 2:27 PM. The tour was conducted with the Practice Manager and an RN. In one of the patient rooms was a plastic container with approximately 20 used instruments in it. Approximately 10 of the 20 instruments had dried blood on them. The RN was asked about the dirty instruments. She stated she did not know how long they had been in the plastic container. She stated the instruments were cleaned and sterilized at the end of the week.

An interview was conducted with the Practice Manager and the VP of Clinical Services on 12/02/22 beginning at 9:00 AM. The VP of Clinical Services confirmed the instruments should have been kept moist or presoaked and should not have been allowed to dry with blood prior to cleaning based on CDC guidelines.

3. A facility policy titled, "Hand Hygiene-CDC Guidelines" dated 6/2021, stated "The CDC has recommended guidelines on when to use non-antimicrobial soap and water, an antimicrobial soap and water or an alcohol-based hand rub ... After coming in contact with patient's intact skin, i.e., taking a patient's blood pressure, pulse, lifting/moving the patient ... After contact with medical equipment/supplies in patient areas." This policy was not followed. An example includes:

On 11/29/22 beginning at 11:15 AM, a tour of the MVH Endoscopy center was conducted and Patient #1's upper endoscopy procedure was observed. Patient #1 was a 38 year old female scheduled for an upper endoscopy for reflux. Patient #1 was observed from admission until completion of procedure. The Anesthesiologist in the procedure room was observed wearing gloves. He inserted medications into Patient #1's IV, touched the side rail, charted on his bedside computer, then dropped a syringe with white medication on the floor. He picked up the syringe from the floor and then discarded the syringe. Throughout the above observations the Anesthesiologist did not remove gloves or perform hand hygiene. At the end of the procedure, the Anesthesiologist pushed Patient #1 out of the GI Lab on the stretcher, wearing the same gloves. He touched the GI Lab door with contaminated gloves.

On 11/29/22 beginning at 11:30 AM , the Endoscopy Manager was interviewed and she confirmed the Anesthesiologist should have performed hand hygiene and replaced his gloves.

The hospital failed to maintain a sanitary environment.



42316

4. The facility failed to ensure supplies ready for patient use were kept current and failed to ensure single use supplies were used on only one patient.

An HOPD urgent care clinic was observed on 11/29/22 beginning at 10:15 AM. The following expired supplies were found in the clinic:

- Three boxes of sterile surgical blades expired 1/2012
- Two boxes of sterile surgical blades expired 4/2015
- One box of sterile surgical blades expired 12/2010
- One box of sterile surgical blades expired 12/2011
- Two bottles of iodoform packing strips, listed as single patient use, opened and available for use
- One surgical cautery tip, listed as single patient use, open and available for use
- Five sterile eye instruments expired 6/2021, 8/2021, 10/2022, 4/2020, and 10/2022
- One bottle phenylephrine hydrochloride 10% expired 9/2021
- One sterile flexible caustic applicator expired 8/2021
- One sterile ENT instrument expired 10/2022
- One bottle of cyclopentolate expired 9/2020

The Urgent Care Practice Manager was present for the observations and confirmed the supplies that were expired and opened, and confirmed they should not have been available for patient use.

The facility failed to maintain a sanitary environment.

Based on observation, CDC guidelines review, record review, policy review, facility document review, Idaho Board of Nursing Rules review, AAMA website review, personnel file review, RXlist.com review, and staff interview, it was determined the facility failed to ensure HOPDs met the needs of patients in accordance with acceptable standards of practice. Findings include:

Refer to A - 410 as it relates to unlicensed personnel administering IV starts and IV medications in an HOPD.

Refer to A - 749 as it relates to the facility's failure to maintain a sanitary environment in HOPDs.

Refer to A - 1081 as it relates to the facility's failure to ensure HOPD nursing competencies were signed off by licensed staff.

Based on policy review, personnel file review, and staff interview, it was determined the facility failed to ensure services were provided in accordance with acceptable standards of practice for 1 of 5 HOPD employees (Staff A) whose personnel files were reviewed. This resulted in licensed nurse competencies being signed off by a UAP. Findings include:

A facility policy titled, "Urgent Care: Nurse Education and Training," revised 8/2020, was reviewed. It stated, "New employees shall participate in the Urgent Care Center orientation program under supervision of the Registered Nurse (RN) or LPN on duty," and "participation shall be documented on the Orientation Record, which includes the date the procedure is observed and performed and the signature of the RN/LPN who supervised the participant." This policy was not followed. An example includes:

A staff list for an HOPD urgent care clinic was provided. It listed Staff A as an LPN. It listed staff B as an MA.

According to the AAMA website, accessed 12/07/22, CMAs are credentialed (https://www.aama-ntl.org/medical-assisting/what-is-a-cma). In the state of Idaho, MAs and CMAs do not hold a license.

Staff A's personnel file was reviewed. It included competencies for "General Nursing." The competencies were signed off by Staff B, an MA. It was unclear how the MA, a UAP, could sign off on nursing competencies.

The VP of Clinical Services for Urgent Care and the DCS for Urgent Care were interviewed on 12/02/22 beginning at 8:45 AM. Staff A's personnel file was reviewed in their presence. The VP of Clinical Services stated only RNs and LPNs could sign off on staff competencies. She reviewed Staff A's personnel file and confirmed the competencies should not have been signed off by the MA.

The facility failed to ensure nursing competencies were signed off by licensed staff.

46933

Based on observation, policy review, and staff interviews, it was determined the facility failed to meet the definition of an ED and failed to meet emergency needs of patients presenting to the ED for 9 of 11 ED patients (Patients #6, #7, #8, #9, #10, #13, #14, #15, and #16) whose records were reviewed. This had the potential to put all patients presenting to the hospital with an emergency medical condition at risk of injury, harm, impairment, or death due to the ED not being fully equipped and staffed to handle patient emergencies. Findings include:

1. The facility failed to ensure staff were trained to work in the ED.

The MVH ED opened on 9/30/22. A policy dated 11/2022 and titled, "MVH Emergency Services: Staff Orientation" stated, "Emergency Services orientation shall include, but not be limited to:
a. General orientation to MVH Emergency Services
b. Introduction to the MVH Emergency Services policy and procedure manual
c. Introduction to nurses' documentation forms
d. Introduction to MVH Emergency Services forms
e. Introduction to MVH Emergency Services equipment
f. Safety Manual
g. Fire and Emergency Management manuals
h. Emergency Services-specific security measures in place
i. Admission of patients to MVH Emergency Services
j. Discharge of patients from MVH Emergency Services
k. Criteria to identify potential abuse victims and potential abusers
l. Provider referrals
m. Transfer procedures to outside facility following HIIPA [sic] guidelens [sic]
n. Crash cart
o. Skills Checklist"

This policy was not followed. Examples include:

On 11/30/22 beginning at 3:35 PM, the DON and the Medical Surgical Manager were interviewed and ED competencies were requested for staff who worked in the ED. No competencies were provided that were specific to the ED. The Medical Surgical Manager was asked if there were any competencies, code blue drills, or specific emergency training done in the ED. The Medical Surgical Manager stated no mock codes were done and, "we are working on competencies for the ED."

On 12/01/22 beginning at 11:15 AM, the Medical Surgical Charge RN who also covered the ED was interviewed and asked what training was provided in the ED. He stated the training consisted of a tour of the ED and the location of forms and paperwork.

The facility failed to provide adequate emergency training per facility policy.

2. The hospital's ED did not have dedicated staff.

On 11/30/22 beginning at 3:35 PM, the DON and the Medical Surgical Manager were interviewed. Surveyors requested an ED staff schedule. When asked how staffing worked in the ED, the Medical Surgical Manager stated there was not a dedicated ED staff schedule. She stated the Charge RN who was working on the Medical Surgical floor would get an alert from communications to go to the ED to meet the patient. Both were asked if staff were physically present in the ED at the time of the interview, they said, "no."

MVH shared a building with a hospital called IFCH. MVH was on one side of the building and IFCH was on the other side of the same building. They shared a common main entrance. A physician coverage schedule for MVH's ED was provided. It listed one ED physician as sole coverage 24/7 from 10/01/22 to current. Additionally, it had documented the ED Physician was also scheduled at IFCH's ED. Of the 61 days from 10/01/22 through 11/30/22, the ED physician was scheduled at both ED's 25 times. It was unclear how the physician would provide emergency coverage in both EDs at the same time.

The ED Physician was interviewed 11/30/22 beginning at 2:00 PM. When asked who provided coverage for MVH ED he stated he was the sole for the MVH ED. He stated the hospital was working on completing a contract with a physicians group to provide more coverage. When asked if he physically saw patients in the MVH ED, he stated he tries to see the patients at MVH. He stated if he was working in IFCH while covering MVH, he would have the patient transferred to IFCH because more services are provided at IFCH. He stated he was the transferring and accepting physician when he covered both ED's.

The facility failed to provide dedicated ED staff.

3. There was no documentation of stabilizing treatment, diagnostic testing, or assessment by a physician prior to transfer in 9 of 11 patients (Patients #6, #7, #8, #9, #10, #13, #14, #15, and #16 ) whose ED records were reviewed.

a. Patient #7 was a 59 year old female who presented to the ED on 11/22/22 at 5:50 PM with a chief complaint of "blood in stool."

Patient #7's medical record included a history of stroke and gastric bypass. Patient #7"s medical record included a pain rating of 9 out of 10 in her knee and abdomen, with 10 being the worst pain. Patient #7's vital signs were taken. There was no documentation throughout Patient #7's record of diagnostics or treatment provided.

Patient #7's medical record included a note by an RN dated 11/22/22 at 6:08 PM. It stated "Pt came to MVH ER complaining of blood in the stool and pain in her knee and abdomen. Pt explained history of stroke, gastric bypass and total knee surgery."

The next note in Patient #7's record dated 11/22/22 at 6:06 PM stated, "Called [ED MD on-call] and received verbal order to transfer patient to IFCH ER"

Patient #7's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer. When asked if the ED Physician assessed Patient #7 prior to her transfer, she stated there was no documentation.

b. Patient #8 was a 72 year old male who presented to the ED on 11/20/22 at 8:32 AM with a chief complaint of "pain in legs."

Patient #8's record included a nurse's note at 8:37 AM which stated, "pt reported with fluctuating leg pain up to 10/10. I did a head to toe assessment and called [ED MD on-call]. He gave a verbal to transfer to IFCH ER." The nursing assessment stated, "irregular heartbeat ... BLE weakness." The record stated Patient #8's medical history included "cardiac ablations x2, PE, DVT, BLE edema, irregular heartbeat." Patient #8's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for Patient #8.

The ED MD was interviewed on 11/30/22 beginning at 2:00 PM. Patient #8's chart was reviewed in his presence. When asked if he came to the ED to see Patient #8, he replied, "no, I directed them to send to IFCH ED and then I headed in." When ED MD was asked if this transfer to IFCH ED was different than a transfer to another hospital, he replied, "nope, I call and say they are coming."

c. Patient #9 was a 62 year old male who presented to the ED on 11/16/22 at 12:59 PM with a chief complaint of "sent by [name] Medical Group for fall work up."

Patient #9's record included a nurse's note, not timed, which stated, "Pt was supposed to report to IFCH ER but ended up at MV [Mountain View] ER. I called [name] PA and got a history on the patient and what orders he was wanting. I called [ED MD on-call] and orders were received to transfer to IFCH ER." There was no documentation Patient #9 was seen by a physician prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation to indicate patient #9 was seen or assessed by a physician prior to transfer.

d. Patient #10 was an 81 year old male who presented to the ED on 11/02/22 at 7:49 AM with a chief complaint of "pain in left leg/thigh weakness."

Patient #10's medical record stated he refused vital signs. The nurse's note stated, "pt arrived with c/o pain in left leg and increase in swelling ... but never had pain [before]. Called [ED MD on-call] and discussed ... ordered to transfer to IFCH. Pt stated he wanted what was going to be the fastest and declined any more assessment with me and wanted to go to the ER." Patient #8's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer of Patient #10.

e. Patient #13 was a 63 year old female who presented to the ED on 11/01/22 at 5:33 PM with a chief complaint of shortness of breath.

Patient #13's record included the Emergency Care Record Assessment which stated, "difficulty swallowing and clearing food ... pain: headache shooting into back. pain...4/10; ... SpO2 [oxygen level] =87% on RA [room air] at 5:50 PM."

Patient #13's medical record did not include documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for Patient #13.

f. Patient #14 was a 21 year old male who presented to the ED on 10/01/22 at 1:36 PM with a chief complaint of "cut on head from gun scope."

Patient #14's record included a nurse's note at 1:25 PM which stated: "V.O. [verbal order] Dr. [ED MD]. Transfer to IFCH ER."

Patient #14's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for Patient #14.

g. Patient #15 was a 20 year old female employee of the hospital who presented to the ED on 11/15/22 at 11:12 AM with a chief complaint of "chest pain and SOB [shortness of breath]" while at work. A rapid response was called.

Patient #15's record did not include a nursing assessment. A physician note stated a call was received from the physician on the rapid response and Patient #15 would be transferred to IFCH ED, however Patient #15's record did not include assessment by an ED physician at MVH. Additionally, there was no time of arrival, vital signs, or disposition listed in the ED record.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or ED provider assessment prior to transfer for Patient #15.

h. Patient #16 was a 57 year old female who presented to the ED on 10/23/22 at 12:35 PM with a chief complaint of "weakness."

Patient #16's medical record included the Emergency Care Record Assessment which stated, "Pt c/o [complains of] headache 5/10." A nurse's note stated, "Pt taken to IFCH ER per [ED MD] verbal order."

Patient #16's medical record did not include documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for Patient #16.

i. Patient #6 was a 4 year old female who presented to the ED on 11/26/22 at 10:40 PM with a chief complaint of "left ear pain."

Patient #6's medical record included a nurse's note which stated, "[ED MD] notified, he instructed us to transfer patient to IFCH ER."

Patient #6's medical record did not include any documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed there was no documentation of diagnostics, stabilizing treatment, or provider assessment prior to transfer for patient #6.

4. Incomplete documentation regarding patient transfers was found in 5 of 11 patients (Patients #8, #9, #10, #15, and #16) whose ED records were reviewed.

a. Patient #8 was a 72 year old male who presented to the ED on 11/20/22 at 8:32 AM with a chief complaint of "pain in legs."

Patient #8's transfer record was incomplete. The following sections were left blank:

- Accepting physician
- Time contacted
- Mode of transportation.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed Patient #8's emergency care and transfer records were incomplete.

b. Patient #9 was a 62 year old male who presented to the ED on 11/16/22 at 12:59 PM with a chief complaint of "sent by [name] Medical Group for fall work up."

Patient #9's medical record did not include a "Patient Transfer Record" form. A request for the Patient Transfer Record form was made on 12/01/22 at 1:45 PM. The transfer record was not provided prior to survey exit.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed Patient #9's record was incomplete.

c. Patient #10 was an 81 year old male who presented to the ED on 11/02/22 at 7:49 AM with a chief complaint of "pain in left leg/thigh weakness."

Patient #10's transfer record was incomplete. There was no accepting physician name or time documented. There was no documentation of a report called to accepting hospital.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed the transfer record for Patient #10 was incomplete.

d. Patient #15 was a 20 year old female employee of the hospital who presented to the ED on 11/15/22 at 11:12 AM complaining of chest pain and SOB while at work. A rapid response was called.

Patient #15's transfer record was incomplete. There was no accepting physician name or time documented There was no document of report called or time of transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed the transfer record for Patient #15 was incomplete.

e. Patient #16 was a 57 year old female who presented to the ED on 10/23/22 at 12:35 PM with a chief complaint of "weakness."

Patient #16's transfer record was incomplete. There was no name, title, or time of report called prior to transfer.

The DON was interviewed 12/01/22 beginning at 10:30 AM. She confirmed the transfer record for Patient #16 was incomplete.

5. It was unable to be determined if all patients presenting to MVH ED were logged and seen by MVH staff.

On 11/29/22 beginning at 3:30 PM, the Quality Assurance Manager provided a tour of the ED and walked surveyors through the ED registration process. Two non-clinical front desk staff were stationed in the main entrance of the lobby in front of a wall with a directory. The wall was broken into two sections, one for Mountain View Hospital and one for Idaho Falls Community Hospital. The directory for MVH included "EMERGENCY" in white lettering. The directory for IFCH included "EMERGENCY" in red lettering. Front desk staff were asked which ED do patients with chest pain get directed to. Front desk staff stated, "anything with the heart goes to IFCH." The MVH Admissions Manager joined the interview at the front desk with surveyors. The Admissions Manager stated that patients decide which ED they want to go to, "it's patient's choice." The Admissions Manager was asked what the process was if a patient arrived with a medical emergency and unable to communicate. The Admissions Manager stated that staff would call a "Rapid Response or Code Blue." The Admissions Manager said if the patient is bleeding, has shortness of breath they would call the Rapid Response team, if patient has chest pain the Code Blue team would be called. A form titled, "MVH EMTALA" that is used by non-clinical front desk staff was provided and states:
"IMMIDIATELY [sic] CALL A RAPID RESPONSE IF PATIENT IS
-BLEEDING
-SHORTNESS OF BREATH
-IN IMMIDIATE [sic]/URGENT NEED OF CARE
IMMEDIATELY CALL A CODE BLUE IF THE PATIENT IS HAVING CHEST PAIN"

The Admissions Manager continued to walk surveyors through the process of an ED registration. An admissions person would, "walk or wheelchair" the patient to the MVH ED after notifying communications that a there is a patient that has arrived for the ED. Communications sends out a group text to the med-surg charge RN, admission staff, and ED MD. The Admissions Manager stated, "admission person stays with the patient until RN arrives" in the ED. Surveyor confirmed with Admissions Manager that admission staff have no medical licenses or training. No ED staff were present in the ED during this observation.

The Medical Surgical charge nurse who was covering the ED was interviewed 11/30/22 beginning at 2:27 PM. When asked what patients are treated in the MVH ED she stated anyone who needs minimal treatments, xrays, and sutures. When asked the process for a patient presenting with chest pain to the MVH ED, she stated she would immediately wheel the patient down to IFCH ED for the fastest treatment, and contact the MD when taking the patient across the hosptial.

It was unable to be determined if all patients presenting to MVH ED were logged and seen by MVH staff.

The facility was notified of an immediate jeopardy at Emergency Services tag 1100 on 12/01/22 at 12:00 PM. A plan of correction was submitted and accepted on 12/01/22 at 4:40 PM. The plan stated, "The MVH Emergency Services department will close immediately, effective 02DEC2022 @ 0800 AM. All Emergency signs/signage will be removed/ or covered. Immediate steps will be taken to train all staff that the Mountain View Hospital does not currently have an Emergency Room. Frontline staff will be instructed to tell the public Mountain View Hospital does not currently have an Emergency Room and all persons seeking Emergency Room Services will be directed to Idaho Falls Community Hospital's Emergency Room." On-site verification of the plan's implementation was completed on 12/02/22 at 9:50 AM and the immediate jeopardy was removed.