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Based on review of medical records, policies, documents, personnel files, staffing schedules, Idaho state law, and staff interview, it was determined the facility failed to ensure its organizational structure was sufficient to direct safe patient care. This resulted in lack of UAP and pharmacy oversight, ineffective/absent policies, and had the potential for poor patient outcomes for all patients receiving care at the facility. Findings include:

Refer to C 241, as it relates to the failure of the Governing Body to assume full responsibility for determining, implementing, and monitoring UAP policies to ensure quality patient care was provided in a safe environment.

Refer to C 270, Condition of Participation: Provision of Services, coordination of services, and associated standard level deficiencies, as they relate to the failure of the facility to ensure systemic practices were developed, implemented, and monitored for all patients receiving care at the facility.

Refer to C 271, as it relates to the failure of the facility to ensure skilled nursing care was administered in accordance with appropriate written policies.

Refer to C 276, as it relates to the failure of the facility to ensure a system, limiting access to drugs and biologicals to appropriately licensed personnel, was in place.

Refer to C 297, as it relates to the failure of the facility to ensure RN supervision of unlicensed personnel medication administration.

These systemic negative practices seriously impeded the ability of the facility to provide safe patient care.

Based on review of policies, staffing schedules, facility documents, personnel files, medical records, Idaho state law, and staff interviews, it was determined the Governing Body failed to assume full responsibility for determining, implementing, and monitoring UAP policies to ensure quality patient care was provided in a safe environment. This resulted in 1 of 2 UAP (Staff #1) who functioned as a Registered Nurse and provided patient care without direct supervision, and had the potential for poor clinical outcomes for all patients receiving care at the facility. Findings include:

IDAPA 23.01.01.490 states "The term unlicensed assistive personnel, also referred to as 'UAP,' is used to designate unlicensed personnel employed to perform nursing care services under the direction and supervision of licensed nurses. The term unlicensed assistive personnel also includes licensed or credentialed health care workers whose job responsibilities extend to health care services beyond their usual and customary roles and which activities are provided under the direction and supervision of licensed nurses."

IDAPA 23.01.01.490.01 states "Unlicensed assistive personnel may complement the licensed nurse in the performance of nursing functions, but may not substitute for the licensed nurse."

IDAPA 23.01.01.490.06.a states "Unlicensed assistive personnel may not be delegated procedures involving actions that require nursing assessment or diagnosis, establishment of a plan of care or teaching, the exercise of nursing judgement, or procedures requiring specialized nursing knowledge, skills or techniques."

These Idaho Board of Nursing Rules were not followed.

Staff #3, a medical/surgical floor CN, was interviewed on 5/09/19, beginning at 3:33 PM. She stated she was 1 of 2 preceptors for Staff #1, a UAP and recently graduated ADN. Staff #3 stated Staff #1 was hired as an SN on 4/01/19, started RN orientation on 4/09/19, and applied for her temporary RN license through the Idaho BON on 5/05/19. Staff #3 stated she believed Staff #1 did not have a temporary RN license yet and stated she was unsure when Staff #1 was going to sit for the NCLEX exam. When asked how she performed direct supervision of Staff #1, Staff #3 stated the same patients assigned to her would also be assigned to Staff #1. Staff #3 stated she would directly supervise all of Staff #1's documentation, patient assessments, and medication administration. Staff #3 stated "sometimes Staff #1 is alone with her own patients when assigned to other CNs."

The HR Director was interviewed on 5/09/19, beginning at 4:29 PM. Staff #1, a UAP and recently graduated ADN, was hired by the Interim CNO on 4/01/19 as a "Registered Nurse-Student." When asked for documentation Staff #1 had graduated from nursing school, the HR Director was unable to provide evidence. The HR Director did not keep verification of graduation for Staff #1. The HR Director initiated a phone call in the presence of surveyors with Staff #1's Utah-based nursing school, and was able to verify Staff #1 graduated on 4/26/19; 25 days after accepting a facility position as a "Registered Nurse-Student." The HR Director confirmed Staff #1 was no longer a student, but was not temporarily licensed as an RN. A job description for "Registered Nurse-Student" was provided and reviewed. The job description stated "Under direct supervision, the Student Registered Nurse (RN) is responsible for applying the nursing process through the assessment, planning, intervention, and evaluation and documentation of patient care." A signed copy of Staff #1's job description was requested, but could not be located. It was unclear if Staff #1 was informed of her job description and subsequent duties upon hire. Additionally, it was unclear why Staff #1 was hired as a "Registered Nurse-Student," as she was no longer in nursing school as of 4/26/19. When asked why verification of nursing school graduation and a signed job description were not kept for Staff #1, the HR Director stated the previous HR Director had recently vacated and did not keep complete files.

The Interim CNO and CCO were interviewed together on 5/09/19, beginning at 6:23 PM. When asked for her interpretation of direct supervision of Staff #1, as mentioned in her job description, the Interim CNO stated it meant having a preceptor on-site, but "not at arm's length." The Interim CNO stated Staff #1's preceptors did not have to be with Staff #1 during her duties, but Staff #1's documentation must be reviewed later in the shift. When asked for her interpretation of direct supervision of Staff #1, the CCO (a Governing Body member) stated it meant Staff #1's preceptor should be with her at all times. The Interim CNO and CCO reviewed Staff #1's job description and confirmed the term "direct supervision" was not clearly defined. The Interim CNO stated Staff #1 had assigned patients of her own on 5/07/19, while working with her preceptor, Staff #2. Additionally, the Interim CNO stated Staff #2 and Staff #3 did not track or document supervision or oversight of Staff #1's competencies.

Staff #2, a medical/surgical floor CN, was interviewed via telephone on 5/09/19, beginning at 7:31 PM. She stated she was 1 of 2 preceptors for Staff #1. When asked how she performed direct supervision of Staff #1, Staff #2 stated she would have her own patient assignments, and she would assign Staff #1 with patients of her own. Staff #2 stated Staff #1's patients would still be her responsibility, but Staff #1 would perform patient assessments, documentation, and medication administration. Staff #2 stated Staff #1 had full access to the facility's Omnicell medication dispenser and would independently pull and administer medications to patients. Staff #2 stated "I'm not there every time she [Staff #1] gives medications" and "I don't verify every medication." Staff #2 stated Staff #1 mainly administered antibiotics and oral medications. Staff #2 stated she would review Staff #1's patient documentation regarding interventions, assessments, and medication administration "after the fact" in order to countersign.

A facility document "DAILY STAFF LISTING," dated 5/07/19, was reviewed. The document included Staff #2 as the "Charge RN" from 7:00 AM to 7:00 PM and Staff #1 as the only medical/surgical "RN" from 7:00 AM to 7:00 PM.

A facility document "Omnicell Transactions by User," was reviewed. The document listed medications accessed and removed by Staff #1, for Patient #3 and Patient #4, on 5/07/19:

- Patient #3:

Multivitamin
Metoprolol [cardiac medication]
Vancomycin [IV antibiotic medication]
Glycerin [adult suppository medication]
Atorvastatin [cholesterol medication]
Fluticasone [nasal medication]
Rifampin [tuberculosis medication]

- Patient #4:

Docusate [constipation medication]
Levetiracetam [seizure medication]
Prednisone [steroid medication]
Escitalopram [depression medication]
Metformin [diabetic medication]
Oxcarbazepine [seizure medication]
Clopidogrel [blood thinner medication]

Additionally, the document listed medications accessed and removed by Staff #1 for Patient #5 on 5/07/19; Patient #5 was not assigned to Staff #1 on 5/07/19:

Enoxaparin [blood thinner medication]
Cefazolin [IV antibiotic medication]
Docusate [constipation medication]
Acetaminophen/Hydrocodone [narcotic pain medication]

Staff #1 was interviewed via telephone on 5/10/19, beginning at 10:26 AM. Staff #1 stated she completed her final nursing school exam on 4/26/19, and was attending her graduation ceremony today [5/10/19]. Staff #1 stated she had applied for her temporary RN license, but had not yet received it. Staff #1 stated she would be taking the NCLEX "as soon as possible," but did not have a testing date or time. Staff #1 stated she was hired as an "SN" while she was still in nursing school [4/01/19]. She stated she could not remember if she read and signed a copy of her official job description. Staff #1 stated her clinical background was "a CNA a long time ago" and she confirmed she had not been an LPN. When asked how Staff #2 provided direct supervision for her, Staff #1 stated "[Staff #2] let's me have my own patients and helps if I'm feeling uncomfortable." Staff #1 stated Staff #2 would usually assign her 2 patients during her 12 hour shift. Staff #1 stated she accessed and removed her own medications from Omnicell and administered those medications independently; including narcotics. When asked when Staff #2 would cosign her documentation, assessments, and medication administration, Staff #1 stated "before she [Staff #2] leaves I assume." Staff #1 confirmed she worked a 12 hour shift on 5/07/19, and was assigned Patient #3 and Patient #4 by Staff #2.

The Interim CNO and CCO were interviewed together on 5/10/19, beginning at 11:04 AM. The CCO confirmed the facility did not have a policy that governed direct supervision of UAPs who had graduated nursing school, but had not yet received a temporary RN license. The CCO confirmed the facility did not have a policy that governed access to medications, including narcotics, by UAPs. They both confirmed Staff #1 should not have had access to the facility's Omnicell without a temporary RN license. The CCO confirmed the facility did not have a policy, process, or documented program for nurses who had graduated nursing school, but had not yet received a temporary RN license. The CCO stated the current process for newly graduated SNs transitioning to RNs "was not implemented well."

The Governing Body failed to assume full responsibility for determining, implementing, and monitoring UAP policies to ensure quality patient care was provided in a safe environment.

Based on review of policies, medical record review, and staff interview, it was determined the facility failed to ensure systemic practices were developed, implemented, and monitored for all patients receiving care at the facility. This failure impeded the ability of the facility to effectively provide safe, quality care. Findings include:

1. Refer to C 271 as it relates to the failure of the facility to develop and implement policies governing the administration of nursing care by unlicensed personnel.

2. Refer to C 276 as it relates to the failure of the facility to develop and implement policies addressing the responsibility of pharmacy's control of drug access by unlicensed personnel.

Based on staff interview, and review of state rules, facility policies and medical records, it was determined the facility failed to ensure skilled nursing care was administered in accordance with appropriate written policies for 5 of 5 patients (Patient #1 - #5) whose records were reviewed. The failure to implement written policies had the potential to impact the quality and safety of patient care. Findings include:

Idaho Board of Nursing rules at IDAPA 23.01.01.010.03 states "...Only persons authorized under Board statutes and these rules may administer medications and treatments as prescribed by health care providers authorized to prescribe medications."

Facility policy # HR-535R5, titled "Employee Licensure," dated 7/07/17, stated "...The Department Director and Human Resources share responsibility for establishing initial proof of licensure, as well as establishing ongoing tracking mechanisms for proof of renewals...Employees required to be licensed must submit a current license to the Human Resources Department."

In an interview on 5/10/19 at 10:26 AM, Staff #1 stated she had performed her clinical rotations at the facility and began working on 4/09/19 under the job description "RN Student." She said she was receiving her diploma that day, 5/10/19, but had not yet taken the NCLEX.

In an interview on 5/09/19 at 6:23 PM, the Interim CNO stated there was no written guidance or policy addressing the oversight of new staff. She stated Staff #1 was assigned patients to care for independently beginning 5/01/19.

Medical records for Patients #1 - #5 were reviewed on 5/10/19. The 5 patient records documented assessments performed, as well as medications administered, by Staff #1 without supervision.

For example, Patient #1 was an 87 year old female admitted on 5/01/19 for a fractured right femur. On 5/03/19 Staff #1 assessed Patient #1 at 1:14 PM and administered Digoxin 0.25 mg (a cardiac medication) at 1:14 PM. Staff #1 documented these tasks as having been proxied by Staff #2. However, Staff #2 did not document verification of the tasks performed by Staff #1 until 5:50 PM, over 4 hours later.

Patient care was not performed in accordance with facility policy.

Based on staff interview, personnel record review, medical record review, and review of facility policies, it was determined the facility failed to ensure a system, limiting access to drugs and biologicals to appropriately licensed personnel, was in place. This failure allowed the potential for serious medication errors to occur. This failure directly impacted 5 patients (Patients # 1 - #5) and had the potential to impact the health and safety of all patients treated at the facility. Findings include:

The facility utilized a secured medication system, Omnicell. The system required staff to be authorized access by the pharmacy. The staff then used a unique password to enter the system and remove medications.

During medical record review on 5/10/19, documentation showed Staff #1 had accessed 36 medications from the facility's Omnicell medication system, on 5/03/19 and 5/07/19. The medications included controlled substances, cardiac medications, antidepressants, and antibiotics. Medications removed by Staff #1 included, but were not limited to:

- On 5/03/19, Acetaminophen/Hydrocodone 325/5 and Digoxin were removed for Patient #1.
- On 5/03/19, Acetaminophen/Hydrocodone 325/10 and Lisinopril were removed for Patient #2.
- On 5/07/19, Vancomycin 1 G and Metoprolol 25 mg were removed for Patient #3.
- On 5/07/19, Escitalopram 10 mg and Clopidogrel 75 mg were removed for Patient #4.
- On 5/07/19, Cefazolin 2 G and Acetaminophen/Hydrocodone 325/10 were removed for Patient #5.

Staff #1's personnel record was reviewed on 5/09/19 and did not show evidence of nursing licensure.

On 5/10/19 at 10:00 AM, the Pharmacy Director was interviewed. He confirmed he had granted Staff #1 access to the secured Omnicell medication system. He said access was granted based on "the word of the nurse who was training her." He could not remember who the training nurse was and no documentation was available related to the request or granting of access to the Omnicell medication system. When asked, he stated he did not ensure Staff #1 had licensure and clearance to access medications. He said he "didn't know how far along she (Staff #1) was." He said he felt the clearance process was the responsibility of the training nurse initiating the request.

Facility policy #PH-171R2, titled "USER ID's, EMPLOYEE ID's, AND CODES, OMNICELL," dated 7/07/17, stated "Nursing Director or CNO will provide staff name to Pharmacist for password."

No other policies were available related to access to medication.

The facility failed to ensure drugs and biologicals were managed in a safe, appropriate manner.

Based on medical record review, personnel record review, and staff interview, it was determined the facility failed to ensure all medications were administered by an RN or under the supervision of an RN. This failure impacted 5 of 5 inpatients (Patients #1 - #5) who received medication from unlicensed personnel and whose records were reviewed. This lack of RN supervision had the potential for unsafe medication delivery to patients. Findings include:

Staff #1's personnel record, reviewed on 5/09/19, showed no evidence of nursing licensure. Her job description, dated 4/09/19, showed she had been hired as a Student - RN. The job description was not signed by Staff #1 to indicate she was aware of her responsibilities or limitations.

Medical record review showed Staff #1 administered 36 medications to Patients #1 - #5, on 5/03/19 and 5/07/19. As charge nurse, Staff #2 was responsible for supervising Staff #1 on these dates.

The medications administered by Staff #1, on 5/03/19 and 5/07/19, included controlled substances, cardiac medications, antidepressants, and antibiotics. Examples of medications administered included, but were not limited to:

- On 5/03/19, Acetaminophen/Hydrocodone 325/5 and Digoxin were administered to Patient #1.
- On 5/03/19, Acetaminophen/Hydrocodone 325/10 and Lisinopril were administered to Patient #2.
- On 5/07/19, Vancomycin 1 G and Metoprolol 25 mg were administered to Patient #3.
- On 5/07/19, Escitalopram 10 mg and Clopidogrel 75 mg were administered to Patient #4.
- On 5/07/19, Cefazolin 2 G and Acetaminophen/Hydrocodone 325/10 were administered to Patient #5.

In an interview on 5/09/19 at 7:30 PM, Staff #2 confirmed she was charge nurse and was responsible for direct supervision of Staff #1 on 5/03/19 and 5/07/19. She stated she was not at Staff #1's side at all times and did not verify medications before administration by Staff #1. Staff #2 stated Staff #1 independently administered medications to her assigned patients, and she reviewed Staff #1's documentation at a later time.

In an interview on 5/09/19 at 6:45 PM, the Interim CNO stated there was no written guidance or policy for charge nurses' supervision of UAP. She said the facility did not require documentation of direct supervision by the charge nurse. She defined direct supervision as "having someone on the floor with them."

In an interview on 5/09/19 at 6:30 PM Staff #3, a second CN, defined direct supervision as not allowing the UAP to do anything alone.

In an interview on 5/09/19 at 6:23 PM, the CCO defined direct supervision as being with the UAP at all times.

Medications were not administered by, or under the supervision of, an RN.