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Based on interview and document review, the governing body failed to ensure that the provider appointment/reappointment process and granting of clinical privileges was determined by individual character, competence, training, experience, and judgment.

Failure to ensure that the providers are appointed/reappointed and granted clinical privileges based on individual character, competence, training, experience, and judgment places patients at risk for harm from substandard care.

Findings Included:

1. Review of the hospital document titled, "Amended and Restated Governing Board Bylaws of Cascade Behavioral Health Hospital, LLC," approved 08/25/21, showed that the Governing Board shall appoint only those providers meeting the qualifications prescribed in the Medical Staff Bylaws and other written or unwritten facility standards. The policy showed that the Medical Staff Bylaws shall include a process whereby the Medical Executive Committee (MEC) makes recommendations to the governing board regarding the mechanism used to review credentials and delineate individual clinical privileges and the individual medical staff or Allied Health Professionals appointment and clinical privileges.

The document also showed that a governing board member shall be deemed to be present at a meeting if the member participates in the meeting using a conference telephone, speaker telephone or similar communication device by means of which all persons participating in the meeting can hear each other at the same time. The act of a majority of the Governing board Members present and voting at a meeting at which a quorum is present shall be an act of the Governing Board. An action of the Governing Board may occur without a meeting if consent of the action set forth is in writing or otherwise approved by all Governing Board Members and filed in the Governing Board meeting minutes. A written record of all Governing Board proceedings, attendance, and actions shall be maintained by the Vice Chair or Vice Chair's designee.

Review of the hospital document titled, "Cascade Behavioral Health Hospital Medical Staff Bylaws," effective 06/07/21, showed that each recommendation concerning appointment of a staff member and granting of clinical privileges shall be based upon an assessment of the applicant's individual character, judgment, training, experience, ability, and current competency by the MEC and the Governing Board. They will consider the applicant's proficiency in the following areas: patient care, medical/clinical knowledge and training, practice-based learning and improvement, interpersonal and communication skills, systems-based practice, and professional judgment and individual character that demonstrate a commitment to continuous improvement, ethical practice, cultural diversity, and responsibility.

The document showed that when considering applicants for appointment/reappointment and clinical privileges, the MEC shall review the application, the related documentation and other relevant information, and then forward the entire credentialing file along with a report and recommendation regarding appointment/reappointment status and clinical privileges to the Governing Board.

2. Review of Governing Board and MEC meeting minutes and documents showed the following:

a. MEC meeting minutes dated 06/23/22, 07/05/22, 08/05/22, 08/10/22, 09/02/22, and 10/07/22 showed that committee members were provided with a credentialing file summary for each provider seeking initial appointment or reappointment and clinical privileges. With the exception of the 09/02/22 meeting, all meetings were conducted by email.

b. Governing Board ad hoc meetings for provider appointment/reappointment and credentialing held on 06/24/22, 07/12/22, 08/05/22, 08/10/22, and 09/03/22 showed that the meeting members were provided with an attachment of the providers' credentialing file summaries to review prior to voting.

c. Governing Board ad hoc meeting minutes dated 06/24/22 and 07/12/22 and the attached provider credentialing summaries showed that credentialing summary information was reviewed for 4 providers, and "after MEC recommendation, review of required license/education, certifications, peer references and competence data," the governing board approved all requests without changes.

d. Governing Board ad hoc meeting minutes dated 08/05/22, 08/10/22, and 09/03/22 showed all provider requests for privileges were approved after MEC recommendation and a "thorough review of application, peer references, competence data, and privilege request."

3. The investigator reviewed credentialing summaries for 4 providers. The review showed that credentialing summaries were a 1 to 2 page document that briefly outlined the applicant's specialty, appointment status (active, courtesy, consulting, Allied Health), privileges requested, professional license number and expiration, school(s) attended and graduation date(s), board certification date and expiration, if applicable, disciplinary action, malpractice insurance provider, amount, and claims history, names of 2 references and recommendation status, dates of data bank queries (Office of Inspector General and National Provider Data Bank) and status (clear), health status, and focused/ongoing professional practice evaluation status. Document review showed that 2 of 4 credentialing summaries failed to list the privileges requested (Staff #1 and Staff #2).

4. On 10/20/22 at 1:00 PM, Investigators #1 and #2 interviewed the Chief Medical Officer (Staff #9) via telephone. Staff #9 stated that when credentialing reviews were conducted via email, the MEC members receive a 1-2 page document that outlines the providers credentialing history, experience, any revocation of privileges. He stated that most of the provider credentials were approved electronically and during ad hoc meetings, and only credentialling summaries, not the entire credentialing files, were included as attachments.

5. On 10/26/22 at 6:00 PM, Investigators #1 and #2 interviewed 2 members of the Governing Board, including the Chief Executive Officer (Staff #7) and the Corporate Director of Quality and Compliance (Staff #8). During the meeting, Staff #8 confirmed that the Governing Board's ad hoc meetings for provider credentialing were occurring mostly by email and stated that the hospital was not including the entire credentialing files for the Governing Board members to review prior to voting. Staff #8 stated that she recently informed the executive administrative assistant that the entire file needed to be scanned and attached for the board members to review remotely prior to voting.
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Based on observation, interview, and document review, the hospital failed to ensure that nursing staff administered medications according to provider orders, hospital policies and procedures, and accepted standards of practice for 3 of 3 patient records reviewed (Patients #2, #3, and #4).

Failure to ensure that nursing staff administer medications according to provider orders, hospital policies and procedures, and accepted standards of practice places patients at risk for harm.

Findings included:

1. Review of the hospital policy titled, "Medication Administration and Records," policy ID PHR-159,
last reviewed 09/21, showed that before administering patient medication, the nurse will compare the final dosage form of the drug and the entry on the medication administration record (MAR) to confirm that the drug, dose, and route of administration are correct, and verify that there are no contraindications present. The document showed that the MAR will include nursing comments for clinical interventions ordered by the provider including blood pressure/vital sign monitoring, weekly weights, and blood glucose monitoring.

Review of the hospital policy titled, "Medication Documentation," policy ID PC.M.131, last reviewed 05/21, showed that after a patient has taken a medication, the nurse will cross through the time the medication was administered and sign initials next to the time. The document showed that if a medication is not administered, the nurse will initial under the time the medication was due, circle both the time and the initials, chart the reason the medication was not given, and document on the MAR if the provider was notified (with date and time of notification).

Review of the hospital policy titled, "Vital Signs with Parameters, Weights, and I & O," last reviewed 07/22, showed that if vital signs are outside of designated parameters, the nurse shall assess the patient for symptoms, administer PRN (as needed) medications as ordered and recheck the vital signs in one hour or contact the provider if no PRN medication is ordered, and document any communication in the progress notes, including the provider's response to the information.

Review of the hospital policy titled, "Documentation Protocols," policy ID PC.DP.300, last revised 09/21, showed that all medical records are to be accurate, truthful and complete. The policy showed that assessments and observations, including vital signs, are not to be documented after the end of the shift. All entries are to be confirmed by written signature, date, time, and credentials.

2. Review of patient medical records showed the following:

a. On 10/11/22 at 8:00 PM, Patient #2 was admitted for voluntary treatment of major depressive disorder with psychosis. On 10/13/22 at 1:33 PM, the patient informed the provider that he had a history of cardiomyopathy (a disease where the heart loses its ability to pump effectively) and that he wanted to resume his home medication treatment of carvedilol. The Medical Progress Note showed that the patient was unsure of his home dose, and the provider ordered carvedilol 6.25 mg, one tablet by mouth twice a day, with instructions to hold for a systolic blood pressure less than 120 mm/Hg or a heart rate under 60.

MAR documentation showed that starting 10/13/22, Patient #2 was scheduled to receive carvedilol 6.25 mg by mouth twice daily at 9:00 AM and 9:00 PM, with instructions for the nurse to hold the medication if the patient's systolic blood pressure was less than 120 or pulse was less than 60.

On 10/17/22 at 9:00 PM, the nurse documented a blood pressure of 115/62 and a heart rate of 65 and crossed out and initialed beneath the administration time indicating that the medication was given, despite a systolic blood pressure of less than 120.

On 10/18/22 at 9:00 PM, the nurse documented initials beneath the administration due time. The investigator found no evidence showing that the nurse assessed the patient's blood pressure or heart rate before administering the medication. The administration time was not crossed out as required by hospital policy, but the manner of documentation was consistent with other medications that were administered to the patient during the shift, and there was no documentation showing that the medications were held or that a provider was notified that medications were not given. Nursing reassessment documentation showed that the patient was compliant with all medications on day and evening shifts.

On 10/20/22 at 6:10 AM, the graphic flow sheet showed that Patient #2 had a blood pressure of 122/74 and a heart rate of 61. At 9:00 AM, the nurse documented her initials under the administration due time but did not cross out the time indicating that the med was given. There was no documentation that the patient's blood pressure and heart rate were reassessed prior to administering the 9:00 AM dose.

MAR documentation showed that on 10/21/22 at 9:00 AM, the nurse wrote her initials under the time and recorded the patient's blood pressure at 118/78 and heart rate of 61. At 9:00 PM, the nurse crossed out the time, initialed next to it, and documented 112/58 and 61. There was no documentation on the MAR or the nursing reassessment sheets showing that either dose of the medication was held for a systolic blood pressure less than 120 as ordered by the provider.


b. On 10/18/22, Patient #3 was admitted for voluntary treatment of alcohol dependence. Patient #3 had a medical history of high blood pressure and reported that he took metoprolol 100 mg by mouth once a day and lisinopril 40 mg by mouth once a day. Review of the medication reconciliation orders showed that upon admission, the provider gave a telephone order to continue the patient's home blood pressure medications.

On 10/19/22 at 1:00 AM, the clinical Institute Alcohol Withdrawal Assessment record showed that Patient #3's blood pressure was 161/94. On 10/19/22 at 1:45 AM, the nurse received a telephone order to administer clonidine 0.1 mg by mouth every 8 hours as needed for a systolic blood pressure over 160 or diastolic blood pressure over 100. Review of the MAR showed that the nurse documented a dose of clonidine 0.1mg was administered at 2:40 AM. In the same box, the nurse documented the patient's blood pressure result that was recorded at 1:00 AM (161/94), and "recheck 140/86," but the nurse failed to document the time that the blood pressure was rechecked and did not initial the entry. It was unclear to the investigator if the nurse failed to obtain a blood pressure reading within 60 minutes of administering the medication to the patient, or if the nurse obtained the patient's blood pressure following administration of the medication but forgot to date and initial the entry on the MAR.

c. On 10/06/22, Patient #4 was admitted to the facility for treatment of alcohol abuse. On 10/22/22 at 6:53 AM, the nurse documented that the provider was notified for the patient's high blood pressure reading of 187/81 and a heart rate of 81, and an order was received to give Cozaar 25 mg by mouth now for high blood pressure.

Review of the MAR showed that the nurse administered Cozaar 25 mg by mouth to the patient at 6:55 AM. The patient's regular dose of Cozaar 25mg by mouth was scheduled at 9:00 AM, but the nurse documented that the dose was administered at 6:55 AM. The investigator found no evidence of an order to administer the 9:00 AM dose early.

3. During an interview with investigators on 10/26/22 at 2:50 PM, the Nurse Manager (Staff #11) stated that when nurses administer cardiac medications, it is the expectation that staff assess the patient's blood pressure and heart rate before administering the medication. Staff #11 stated that nursing staff should check the patient's blood pressure and heart rate no more than an hour before administering cardiac medications, even when there were no parameters to hold the medication. During the interview, Staff #11 confirmed the investigator's findings that staff administered medications when the patients' vital signs were outside of the ordered parameters. Staff #11 also stated that the order to administer Patient #4's Cozaar 25mg by mouth now was unclear and should have been worded differently. He stated that he was not able to tell if the order was for an additional dose of medication or to give the 9:00 AM dose early.
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