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Based on observation and staff interview, it was determined the CAH failed to ensure inpatient premises were clean and orderly. This had the potential for patients to receive inpatient care in an unsanitary environment. Findings include:

1. A tour of the CAH was conducted on 10/16/17, beginning at 1:00 PM, in the presence of the CNO. During the tour of the PACU, an approximate 12-inch wallpaper border encompassing the ceiling perimeter was observed to be peeling and torn in multiple places.

The CNO was interviewed on 10/16/17, beginning at 1:17 PM. He confirmed the wallpaper was in disrepair and needed to be removed from the inpatient care area.

2. A tour of the CAH's inpatient rooms was conducted on 10/17/17, beginning at 7:35 AM, in the presence of the Director of Facilities. During the tour, wallpaper was noted to be peeling and torn in multiple places in patient rooms 3, 4, 5, 6, 7, 8, and 9.

The Director of Facilities was interviewed on 10/17/17, beginning at 7:56 AM. He confirmed the wallpaper located in the patient rooms was in disrepair and needed to be removed from those inpatient care areas.

The CAH failed to ensure inpatient premises were clean and orderly.

Based on medical staff bylaw review, CAH staff scheduling review, and staff interview, it was determined the CAH failed to ensure a physician periodically reviewed and signed a sample of records of patients who had been cared for by a mid-level practitioner. This impacted all patients who were treated by the FNP in the ED. Lack of physician record review, verified by signature, had the potential to negatively impact the quality of patient care. Findings include:

The CAH's medical staff bylaws, dated 1/26/15, stated "Patients being treated by AHPs and other non-physician practitioners in [CAH's name] shall be under the general care of a physician."

Additionally, the CAH's medical staff bylaws, dated 1/26/15, defined an AHP as "an individual, other than a licensed physician, podiatrist, optometrist, or dentist..."

A review of the CAH's staffing schedule showed an FNP was assigned a 12-hour shift in the ED weekly, for direct patient treatment.

In an interview on 10/18/17 at 3:00 PM, the CNO and the Director of Quality Assurance stated the FNP treated patients independently, sanctioned by IBN rules, and confirmed a physician did not periodically review and sign a sample of her patient treatment records.

The CAH failed to ensure a physician's periodic review and signature of mid level practitioners' outpatient treatment records.

Based on medical record review, CAH policy review, and staff interview, it was determined the CAH failed to ensure healthcare services were provided in accordance with appropriately written policies for 1 of 1 ED patients (Patient #8) who were placed on a court-ordered psychiatric hold and whose record was reviewed. This resulted in services not being furnished in a consistent manner, and had the potential to result in avoidable, adverse patient outcomes. Findings include:

A CAH policy "Suicide Precautions Protocol," reviewed 3/2017, stated "Level III Serious suicide risk...observation with 1:1 contact at all times. Indications: verbalizes clear intent to harm self, has concrete/specific plan...". This policy was not followed.

Patient #8 was a 54 year old female who was seen in the ED on 5/10/17, with a diagnosis of suicidal ideation. She was placed on a court-ordered psychiatric hold on 5/10/17.

Patient #8's medical record included a physician order, dated 5/10/17, signed by the physician. The order stated Patient #8 was placed on a 24-hour medical hold due to suicidal ideation with concrete plan.

Patient #8's medical record included a nurse's note, dated 5/10/17, signed by an RN. The note stated "Patient has plan for suicide attempt. pt [sic] states that the guns have been hidden...".

Patient #8's medical record did not include documentation of 1:1 contact by CAH staff. It could not be determined which staff was responsible for Patient #8's continuous 1:1 contact status.

The CNO was interviewed on 10/18/17, beginning at 3:01 PM, and Patient #8's medical record was reviewed in his presence. He confirmed Patient #8 was a "Level III" risk and should have been on 1:1 contact at all times. The CNO confirmed the CAH's suicide precautions policy was not followed by nursing staff.

The CAH failed to ensure healthcare services were provided in accordance with appropriately written policies.

Based on CAH policy review and staff interview, it was determined the CAH failed to ensure policies were developed with the advice of the mid-level practitioners and reviewed annually. This had the potential for outdated policy information, which could impact delivery of patient care and health care processes. Findings include:

The Director of Quality Assurance was interviewed on 10/18/17, beginning at 1:15 PM. She stated the CAH had 1 mid-level practitioner, an FNP, who worked exclusively in the ED. The Director of Quality Assurance stated the CAH's FNP did not participate in policy development. She stated the FNP may have previously participated in policy review, but was unable to provide meeting minutes documenting such review.

The CAH failed to ensure policies were developed with the advice of the mid-level practitioners and reviewed annually.

Based on CAH infection control policy review and staff interview, it was determined the CAH failed to ensure a system to identify, report, investigate, and control infections of patients. This failure had the potential for increased infections of all patients receiving care at the CAH. Findings include:

The Infection Control Preventionist was interviewed on 10/17/17, beginning at 7:55 AM, and the "Infection Prevention Policy," updated 3/21/17, was reviewed in her presence.

The Infection Control Preventionist stated the CAH did not currently have a documented, department-wide system to identify, report, investigate, and control infections of patients. She stated the CAH had not chosen, and were not currently following, any nationally recognized infection control guidelines. The Infection Control Preventionist stated the current infection control policy was "incomplete."

The Infection Control Preventionist stated she was not currently collecting infection control data or performing active surveillance duties in the outpatient Physical Therapy Department or Ambulance service. She confirmed the outpatient Physical Therapy Department and Ambulance service were not included in the infection prevention policy, as she "had not thought about it."

The CAH failed to ensure a system to identify, report, investigate, and control infections of patients.

Based on personnel record review, job description review, and staff interview, it was determined the CAH failed to ensure Therapy staff were competent to provide wound care services for 1 of 1 Physical Therapy Assistants, whose personnel record was reviewed. This had the potential for outpatients of the CAH to receive wound care services from staff which were not qualified or competent. Findings include:

The Director of Clinic Operations, who oversaw the CAH's outpatient wound care services, was interviewed on 10/18/17, beginning at 8:00 AM. She stated outpatient wound plans of care were initiated by the DPT, and interventions based on these plans of care were delegated to the PTA. When asked if the DPT provided PTA oversight in regard to wound care, the Director of Clinic Operations stated no. When asked if the PTA had specific wound care competencies, she stated no. When asked if wound care services were outlined in the PTA's job description, the Director of Clinic Operations stated she was unsure.

The PTA's job description, revised 8/2008, signed by the PTA, did not include responsibilities, duties, or expectations related to wound care.

The HR Director was interviewed on 10/18/17, beginning at 8:57 AM, and the PTA's personnel record was reviewed in her presence. The personnel record did not include a PTA competency. The HR Director confirmed it could not be determined if the PTA could safely perform wound care based on personnel record documentation.

The Director of Quality Assurance was interviewed on 10/18/17, beginning at 3:22 PM. When asked if there was a policy which governed outpatient wound care, she stated no.

The CAH failed to ensure the PTA was competent to provide wound care services.

Based on medical record review and staff interview, it was determined the CAH failed to ensure medical records were complete for 1 of 4 ED patients (Patient #5) who transferred to another facility and whose records were reviewed. This had the potential to interfere with the coordination and provision of patient care. Findings include:

Patient #5 was a 64 year old male who was seen in the ED on 5/01/17, with a diagnosis of drug overdose and respiratory distress.

Patient #5's medical record included a "Transfer Form," dated 5/01/17, signed by the physician. The form included a section titled "Medical Risks," which was left blank.

The Director of Quality Assurance was interviewed on 10/18/17, beginning at 2:30 PM, and Patient #5's medical record was reviewed in her presence. She confirmed Patient #5's "Transfer Form" was not complete.

The CAH failed to ensure Patient #5's medical record was complete.

Based on medical record review and staff interview, it was determined the CAH failed to ensure informed consents were properly executed for 2 of 22 patients (#2 and #17) whose records were reviewed. This resulted in a lack of clarity as to whether patients or their representatives were fully informed, or legally competent, to sign consents prior to treatment. Findings include:

1. Patient #2 was a 57 year old female who was seen in the ED on 4/09/17, with a diagnosis of alcohol intoxication.

Patient #2's medical record included an "Ethanol Level" laboratory test, which documented Patient #2's blood alcohol level at 70 mg/dl (reference range is less than 10 mg/dl).

Patient #2's medical record also included an "Authorization for Medical and/or Treatment and Release of Information" consent, dated 4/09/17, signed by Patient #2. Her medical record did not include documentation if she was competent to sign her consent due to alcohol intoxication.

The Director of Quality Assurance was interviewed on 10/18/17, beginning at 2:49 PM, and Patient #2's medical record was reviewed in her presence. She confirmed Patient #2's informed consent was not properly executed.

The CAH failed to ensure Patient #2's informed consent was properly executed.

2. Patient #17 was a 59 year old female who was admitted on 9/17/17, for an outpatient colonoscopy procedure.

Patient #17's medical record included a "Consent for Procedure," dated 9/17/17, signed by Patient #17. The consent included a section for Patient #17 to indicate if she did or did not want blood or blood products as deemed necessary. This section was left blank. The consent included a section indicating who the anesthetizing physician or CRNA performing the procedure would be. This section was left blank.

The Director of Quality Assurance was interviewed on 10/18/17, beginning at 2:40 PM, and Patient #17's medical record was reviewed in her presence. She confirmed Patient #17's informed consent was not properly executed.

The CAH failed to ensure Patient #17's informed consent was properly executed.

Based on medical record review and staff interview, it was determined the CAH failed to ensure transfer forms were dated by the physician for 2 of 4 ED patients (#11 and #21) who were transferred to another facility and whose records were reviewed. This resulted in a lack of clarity regarding authentication of medical record entries. Findings include:

1. Patient #11 was a 70 year old male who was seen in the ED on 5/10/17, with a diagnosis of suicide attempt and drug overdose.

Patient #11's medical record included a "Transfer Form," signed by the physician. The physician's signature was not dated.

The Director of Quality Assurance was interviewed on 10/18/17, beginning at 2:35 PM, and Patient #11's medical record was reviewed in her presence. She confirmed the physician's signature on Patient #11's "Transfer Form" was not dated.

The CAH failed to ensure Patient #11's transfer form was dated by the physician.

2. Patient #21 was a 36 year old male who was seen in the ED on 8/14/17, with a diagnosis of cardiac arrest.

Patient #21's medical record included a "Transfer Form," signed by the physician. The physician's signature was not dated.

The Director of Quality Assurance was interviewed on 10/18/17, beginning at 2:38 PM, and Patient #21's medical record was reviewed in her presence. She confirmed the physician's signature on Patient #21's "Transfer Form" was not dated.

The CAH failed to ensure Patient #21's transfer form was dated by the physician.

Based on observation and staff interview, it was determined the CAH failed to ensure medical record information was safeguarded against destruction by fire damage in 2 of 2 medical record storage areas observed. This had the potential for irretrievable original medical records. Findings include:

1. A tour of the CAH's offsite Medical Records Department was conducted on 10/17/17, beginning at 11:23 AM, in the presence of the HIM Director. During the tour, multiple original, non-archived CAH medical records were observed arranged in manila folders on several shelves. The room where these records were stored did not have a fire suppression system in place.

2. A tour of the CAH's onsite medical record storage area was conducted on 10/17/17, beginning at 12:18 PM, in the presence of the HIM Director. During the tour, multiple original, non-archived CAH medical records were observed arranged in manila folders on several shelves. The room where these records were stored did not have a fire suppression system in place.

The HIM Director was interviewed on 10/17/17, beginning at 12:29 PM. She confirmed both areas used to store original, non-archived CAH medical records were not safeguarded against destruction by fire damage.

The CAH failed to ensure medical record information was safeguarded against destruction by fire damage.

Based on CAH quality document review and staff interview, it was determined the CAH failed to ensure its quality assurance program evaluated all patient care services affecting patient health and safety. This failure prevented the CAH from analyzing all services provided to ensure patients' needs were met. Findings include:

The CAH's "Annual Evaluation," dated 2016, was reviewed. The document included evaluations of all patient care areas except Ambulance and Outpatient Therapy services.

The Director of Quality Assurance was interviewed on 10/17/17, beginning at 9:10 AM, and the "Annual Evaluation" was reviewed in her presence. She confirmed there was no evaluation of the CAH's Ambulance and Outpatient Therapy services. The Director of Quality Assurance stated data collection and analysis for these 2 service areas were not being performed.

The CAH failed to ensure its quality assurance program evaluated all patient care services.