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Based on record review, patient interview, and staff interview, it was determined the facility failed to ensure compliance with Federal laws and regulations related to advanced directives for 7 of 13 adult patients (#1, #7, #18, #19, #28, #30 and #31) whose records were reviewed for advanced directives. This resulted in a lack of documentation in patients' records that they were informed of their right to formulate advanced directives, such as a living will or durable power of attorney. Findings include:

An advanced directive is defined at 42 CFR 489.100 as "a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated." In accordance with the provisions of 42 CFR 489.102(a), the advanced directives regulations apply to CAHs. 42 CFR 489.102(b)(1) requires that notice of the CAH's advanced directives policy be provided at the time an individual is admitted as an inpatient.

42 CFR 489.102(b)(2), states the CAH is required to "Document in a prominent part of the individual's current medical record, or patient care record in the case of an individual in a religious nonmedical health care institution, whether or not the individual has executed an advance directive." The hospital failed to comply with this Federal regulation as follows:

1. Documentation that patients were informed of their options for advanced directives could not be found. Examples include:

a. Patient #1's medical record documented a 66 year old female who was admitted to swing bed status at the hospital on 8/01/12. She was currently a patient as of 8/10/12. Her right leg had been surgically repaired following a fracture.

Documentation whether or not Patient #1 had completed an advance directive was not present in her medical record. Also, no documentation was present whether or not Patient #1 was given the opportunity to develop an advance directive.

Patient #1 was interviewed on 8/07/12 beginning at 11:10 AM. She stated she did not have an advance directive. She stated the CAH staff had not discussed an advance directive with her.

The Admissions Coordinator reviewed Patient #1's medical record on 8/09/12 beginning at 2:15 PM. She confirmed the documentation.

The CAH did not provide information to Patient #1 to assist her to complete an advance directive.

b. Patient #7's medical record documented a 65 year old male, who was admitted to the hospital on 8/04/12 at 7:45 PM for care related to atrial fibrillation (irregular and often rapid heart rate that causes poor blood flow to the body) and sepsis (presence of infectious organisms or toxins created by infectious organisms in the blood) from a urinary origin. Documentation that Patient #7 was provided the option to prepare and advanced directive could not be found in the medical record.

c. Patient #18's medical record documented a 47 year old male who was admitted to the hospital on 8/06/12 at 5:30 PM for care related to chest pain. He also had a history of insulin dependent diabetes and occurrence of a heat attack in 1996. Documentation that Patient #18 was provided the option to prepare an advanced directive could not be found in the medical record.

d. Patient #19's medical record documented an 83 year old female who was admitted to the hospital on 8/07/12 at 3:00 AM for care related to upper abdominal discomfort. She also had a documented history of COPD. Documentation that Patient #19 was provided the option to prepare an advanced directive could not be found in the medical record.

e. Patient #28's medical record documented a 79 year old male who was admitted to the hospital, on 8/08/12 at approximately 7:30 AM, for surgical repair of a right inguinal hernia (a portion of the intestine protrudes through a weak point or tear in the lower abdominal wall.) Patient #28 was discharged the afternoon of 8/08/12 at 2:10 PM according to the "RECOVERY ROOM FLOW SHEET." Documentation that Patient #28 was provided the option to prepare an advanced directive could not be found in the medical record.

f. Patient #30's medical record documented an 84 year old female admitted to the hospital, on 8/09/12 at 9:45 AM, for care related to generalized weakness/fatigue. Her medical history included hypertension and diabetes. Documentation that Patient #30 was provided the option to prepare an advanced directive could not be found in the medical record.

g. Patient #31's medical record documented a 74 year old female who was admitted to the hospital on 8/08/12 at 9:50 PM for care related to a large hematoma on the left leg with a history of deep vein thrombosis. She also had a documented history urinary bladder cancer. Documentation that Patient #31 was provided the option to prepare an advanced directive could not be found in the medical record.

2. The Admissions Coordinator was interviewed on 8/09/12 at 2:15 PM. She confirmed it was not the hospital's practice to document whether patients opted to participate in advanced directives. The Admissions Coordinator also said documentation was not consistent to support the existence of a living will or durable power of attorney that patients may have brought with them when admitted to the facility.

Documentation that patients were provided the right to participate in advanced directives was not consistently found in patients' medical records.



00023

Based on staff interview and policy review, it was determined the CAH's governing board failed to ensure complete policies were developed and implemented and staff were trained to access policies. This resulted in a lack of guidance to staff to enable them to provide care in a consistent manner. Findings include:

1. On 8/10/12 at 8:30 AM, the surveyor attempted to review facility policies. He went to the Administrative Receptionist and asked her to about policies. She stated policies were stored electronically on a program called "Policy Tech." She attempted to access the policies via her computer but was not able to do so. She asked the Clinic Receptionist next to her to retrieve the policies. The Clinic Receptionist was not able to access the policies. The surveyor then went directly to the nursing unit where he asked the staff RN to access the CAH's policies. She attempted to access them but was not able to do so. The surveyor then asked the Nursing Assistant to access the CAH's policies. She attempted to access them but was not able to do so. The surveyor then asked the Charge Nurse to access the CAH's policies. She attempted to retrieve them but also was not able to locate them. The Charge Nurse stated the policies could not be easily accessed for review.

CAH staff were unable to retrieve hospital policies for review.

2. Refer to C276 as it relates to the failure of the hospital to ensure a) the hospital had a legal relationship with all pharmacy staff that provided services and b) the hospital developed policies and procedures which defined and directed the provision of pharmacy services.

Based on observation, staff interview, and review of facility policies, it was determined the hospital failed to ensure health care services were provided consistent with appropriate written hospital policies. This directly impacted 3 of 3 patients (#7, #18 and #19) who were observed while care was being provided by nursing and laboratory staff, and had the potential to impact all patients. These failures had the potential to result in cross contamination and interfere with infection prevention. Findings include:

1. The hospital's policy, titled "Hand Hygiene," and approved on 4/13/11, documented indications for hand washing. Included in this section was direction to the staff to wash hands before having direct contact with patients, with a "non-bacterial or bacterial soap" if hands were visibly soiled. The policy also documented indications for use of alcohol hand cleaner, which stated staff could use an alcohol-based cleaner (instead of handwashing) before direct contact with a patient when hands were not visibly soiled.

Nursing staff failed to practice hand hygiene in accordance with hospital policy as follows:

a. Patient #7's medical record documented a 65 year old male, who was admitted to the hospital on 8/04/12 at 7:45 PM for care related to atrial fibrillation (irregular and often rapid heart rate that causes poor blood flow to the body) and sepsis (presence of infectious organisms or toxins created by infectious organisms in the blood) from a urinary origin.

A RN was observed while administering medications to Patient #7 on 8/07/12, beginning at 8:45 AM. The RN was not observed to wash her hands or use hand sanitizer before entering Patient #7's room.

b. Patient #18's medical record documented a 47 year old male who was admitted to the hospital on 8/06/12 at 5:30 PM for care related to chest pain. He also had a history of insulin dependent diabetes and occurrence of a heat attack in 1996.

A RN was observed while administering medications to Patient #18 on 8/07/12, beginning at 9:00 AM. The RN was not observed to wash her hands or use hand sanitizer before entering Patient #18's room.

c. Patient #19's medical record documented an 83 year old female who was admitted to the hospital on 8/07/12 at 3:00 AM, for care related to upper abdominal discomfort. She also had a documented history of COPD.

A RN was observed while administering medications to Patient #19 on 8/07/12, beginning at 9:15 AM. The RN was not observed to wash her hands or use hand sanitizer before entering Patient #19's room.

The DNS was interviewed on 8/08/13, beginning at 1:30 PM. The hospital's policy and practice related to hand hygiene was discussed. The DNS stated the staff is expected to wash their hands or use hand sanitizer prior to entering and before leaving patients' rooms. She also said the hospital was in the process of installing touchless hand sanitizer dispensers outside each patient room to allow for efficiency and to serve as a reminder to perform hand hygiene.

Hand hygiene was not performed before nursing staff entered patients' rooms as stated in the hospital's policy.

2. The hospital's policy, titled "ROUTINE VENIPUNCTURE PROCEDURE," signed by the Laboratory Director on 5/04/11, included information from a CLIA approved manual, titled "An Introduction to Phlebotomy." The policy included "You must change your gloves immediately if the gloves are visibly contaminated with blood or if they show evidence of perforation, tears, or leaks.

Laboratory staff failed to follow infection prevention guidelines included in the policy as follows:

Patient #19's medical record documented an 83 year old female who was admitted to the hospital on 8/07/12 at 3:00 AM for care related to upper abdominal discomfort. She also had a documented history of COPD.

A laboratory assistant was observed while attempting to draw Patient #19's blood from her left arm on 8/07/12, beginning at 9:15 AM. The lab assistant stated she had unsuccessfully attempted to draw Patient #19's blood before the surveyor entered the room. She said Patient #19's skin and veins were fragile and difficult to access. The lab assistant stopped the procedure and stated she wanted to call another staff member to perform the blood draw. The laboratory assistant was observed wearing gloves when the surveyor entered the room. However, the index finger of the right glove was cut and folded back to reveal the finger.

The Laboratory Manager was interviewed on 8/09/12, beginning at 10:15 AM. The hospital's infection control practices were discussed. The Lab Manager said laboratory assistants should wear fully intact gloves when drawing blood from patients. She confirmed that using gloves with holes or open areas in them was a breech in infection control and prevention.

Gloves were not worn in accordance with hospital policy.

Based on staff interview and review of hospital policies and contracts, it was determined the facility failed to ensure systems for the provision of pharmacy services were developed and implemented. This resulted in a lack of direction to pharmacy personnel and had the potential to negatively impact patient care. Findings include:

1. The DNS was interviewed on 8/07/12, beginning at 8:00 AM. When the surveyor requested to tour the pharmacy and meet with the Director of Pharmacy, the DNS stated the facility was transitioning to a new Director of Pharmacy. She stated the current Director of Pharmacy was a contract employee and was not on site at that time. She said the current Director of Pharmacy was employed by a retail pharmacy and was only available for emergencies. The DNS also stated the incoming Director of Pharmacy was an employee of the hospital, but was away from the facility for a planned vacation, scheduled for the week of survey and the following week. When asked who was overseeing pharmacy services, the DNS stated the hospital had 2 pharmacy technicians who were filling the PYXIS (automated medication management system) machine. The DNS stated they were part of a program that was approved by the Idaho Board of Pharmacy, called a "tech check tech program." The DNS also said the hospital had an agreement with a tele-pharmacy company based in another state to review medication orders and monitor medication administration records.

The DNS then contacted the current Director of Pharmacy by phone and inquired about her availability to meet with surveyors. According to the DNS, the current Director of Pharmacy stated she was available for medication emergencies only, such as the need to fill a medication order for a medication that could not be found in the hospital pharmacy. Another pharmacist, who was the business partner of the current Director of Pharmacy, also worked at the hospital on occasion. The DNS then made arrangements with the business partner to meet with surveyors the following morning.

Surveyors requested copies of contractual agreements for the current Director of Pharmacy and the Director of Pharmacy's business partner. At approximately 4:00 PM of the same day (8/07/12), the DNS informed surveyors that contracts for the current Director of Pharmacy, and Director's business partner, could not be found.

On 8/08/12, beginning at 10:03 AM, the Pharmacist, who was the partner of the current Director of Pharmacy, was interviewed. The Pharmacist stated he last provided coverage for the hospital in October of 2011. He said when he provided pharmacist coverage at the hospital his practice was to process and verify physician orders and fill the PYXIS. When asked to explain the current pharmacy process, he said his understanding was that the hand written physician orders were scanned to the tele-pharmacy, via a specific soft-ware system. He said the tele-pharmacy processed the orders and created the electronic medication administration record. He said PVTs stocked the PYXIS.

The PVT who was also present during the above interview, stated the new/incoming Director of Pharmacy, who was on vacation at the time of the survey, came to the hospital once a week. She said medications were packaged by the PVTs and held from the PYXIS until they were verified weekly by the pharmacist. Additionally, the PVT stated if the technicians were filling the PYXIS with unit dose medications, the technicians checked one another's work. She said the Director of Pharmacy did not directly oversee the process of filling the PYXIS with unit dose medications. The PVT said the new Director of Pharmacy, who was currently on vacation, was monitoring PYXIS reports electronically from a lap top, while on vacation.

A pharmacist was not present in the hospital to direct pharmacy operations and oversee the activities of the PVTs. Two pharmacists who provided services at the hospital did not have a legal/contractual relationship with the hospital.

2. When pharmacy/pharmacist related policies were requested, one pharmacy policy, job descriptions for the pharmacist and PVTs, and a description of the "VERIFICATION TECHNICIAN PROGRAM" were provided. No other pharmacy related policies were provided.

The policy "Pharmacist and support staff, responsibilities of," dated 02/05/2009, did not address the use of PVTs, including the procedure used for the packaging and labeling of medications by the PVTs. Additionally, the pharmacy policy failed to address the supervision of PVTs by the pharmacist, the duties the PVTs were allowed to perform at the hospital, or the ability of PVTs to access the pharmacy when there was no pharmacist on site.

The document titled "VERIFICATION TECHNICIAN PROGRAM" did not state it was an official policy and did not include an approval date. This document discussed packaging and repackaging medications by the pharmacy technicians.

The Acting Administrator and the DNS were interviewed on 8/17/12 beginning at 3:00 PM. They confirmed there were no other policies that specifically described supervision of the PVTs. They also stated the document titled "VERIFICATION TECHNICIAN PROGRAM" had not been approved by the medical staff.

The pharmacy policy failed to define current pharmacy processes.

3. P&T Committee meeting minutes were reviewed. Minutes documented the committee met quarterly in 2011. The documentation for 2012 showed the committee had not met since 1/03/12.

The Quality Assurance Assistant was interviewed on 8/14/12 beginning at 10:20 AM. She stated no P&T Committee minutes were present after 1/03/12.

The Acting Administrator and the DNS were interviewed on 8/17/12 beginning at 3:00 PM. They stated a policy which defined the P&T Committee's duties was not present at the hospital.

The CAH did not provide guidance to the P&T committee.

Based on staff interview and review of quality assurance documents, it was determined the CAH failed to ensure the quality and appropriateness of treatment was evaluated including the investigation of 9 of 9 reported adverse patient events reviewed. Additionally, the CAH failed to ensure all adverse patient events were reported to hospital's adverse event reporting system. This directly impacted 1 of 1 patient (Patient #27) reviewed whose record documented adverse events. This prevented the CAH from identifying processes which could be improved in order to decrease the number of adverse patient events that occurred. Findings include:

1. "OCCURRENCE REPORTS" identified 9 adverse patient events, such as falls, medication errors, and other incidents that occurred between 5/01/12 and 8/01/12. None of these reports documented an investigation of the occurrence or actions that were taken to prevent future occurrences.

The DNS reviewed the "OCCURRENCE REPORTS" with the surveyor on 8/08/12 beginning at 4:20 PM. She stated the occurrences had been investigated but confirmed the investigations were not documented for the 9 "OCCURRENCE REPORTS." She also confirmed actions taken to prevent future recurrences of incidents were not documented. She stated the hospital was changing software programs which monitored adverse patient events. She confirmed the current system did not include documentation that such events were investigated and actions taken to prevent future events.

The CAH did not document the investigation of adverse patient events and actions taken to prevent future events.

2. Not all adverse patient events were reported through "OCCURRENCE REPORTS." Patient #27's medical record contained a physician "Progress Note," dated 6/15/12 but not timed, which documented the patient fell on 6/14/12 and required a CT scan to rule out a head injury. An "OCCURRENCE REPORT" documenting the fall for administrative records was not present.

Also, on 6/20/12 at 9:50 PM, Patient #27's "Patient Notes: Nursing" documented he was "...VERY COMBATIVE CUSSING AT NURSING STAFF AND PULLING, SCRATCHING, PINCHING, AND TWISTING FINGERS AND ARMS OF NURSING STAFF." An "OCCURRENCE REPORT" documenting this incident was not present.

The DNS reviewed the "OCCURRENCE REPORTS" with the surveyor on 8/08/12 beginning at 4:20 PM. She confirmed these incidents were not included in the "OCCURRENCE REPORTS."

The CAH did not complete occurrence reports for all adverse patient events.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure rehabilitative services were provided in accordance with the therapy plans for 2 of 3 swing bed patients (#1 and #27) whose records were reviewed. This resulted in the potential for unmet patient rehabilitative needs. Findings include:

1. Patient #1's medical record documented a 66 year old female who was admitted to swing bed status at the hospital on 8/01/12. She was currently a patient as of 8/10/12. Her right leg had been surgically repaired following a fracture.

A PT evaluation was documented on 8/01/12 at 3:12 PM. The evaluation included a plan for therapy services. The plan stated Patient #1 was to receive therapy 2 times a day for 4 weeks. PT progress notes documented Patient #1 received therapy 1 time on 8/02/12, 1 time on 8/03/12, 2 times on 8/06/12, 1 time on 8/07/12, and 1 time on 8/08/12. No other therapy notes were documented.

The Admissions Coordinator reviewed the medical record with the surveyor on 8/09/12 beginning at 2:15 PM. She confirmed the lack of documented therapy visits and stated the number of PT visits provided did not match the number of visits ordered.

Patient #1 did not receive PT services at the frequency specified in her therapy plan.

2. Patient #27's medical record documented an 82 year old male who was admitted to swing bed status at the hospital on 6/04/12. He was discharged on 7/05/12. His diagnosis was stroke.

A PT evaluation was documented on 6/12/12 at 1:42 PM. The evaluation included a plan for therapy services. The plan stated Patient #27 was to receive therapy 2 times a day for 4 weeks. PT progress notes documented Patient #27 received therapy 2 times on 6/13/12, 1 time on 6/14/12, 2 times on 6/15/12, no visits on 6/16/12 and 6/17/12, 1 time on 6/18/12, 1 time on 6/19/12, and 2 times on 6/20/12. No other therapy notes were documented.

The Admissions Coordinator reviewed the medical record with the surveyor on 8/09/12 beginning at 2:15 PM. She confirmed the lack of documented therapy visits and stated the number of PT visits provided did not match the number of visits ordered.

Patient #27 did not receive PT services at the frequency speficied in the therapy plan.