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Based on record review, policy review, Idaho State statutes, and staff interview, it was determined the CAH failed to ensure ED staff reported potential abuse to appropriate authorities in accordance with State law for 1 of 10 ED patients (Patient #4) who had documented potential assault and whose records were reviewed. This had the potential for poor patient outcomes for all patients receiving care in the ED. Findings include:

Idaho Statutes for Health and Safety, Section 39-1390 stated:

"As soon as treatment permits ... any physician ... shall notify the local law enforcement agency of that jurisdiction upon the treatment of or request for treatment of a person when the reporting person has reason to believe that the person treated or requesting treatment has received:
(a) Any injury inflicted by means of a firearm; or
(b) Any injury indicating that the person may be a victim of a criminal offense."

This Idaho statute was not followed.

A CAH policy, revised 10/08/20, titled "Suspected or Identified Abuse, Neglect and/or Victim of Crime" stated, "I. Mandatory Reporting Obligation...C. Victims of a Crime. As soon as treatment permits, the designated reporter for the facility...must notify the local law enforcement agency that a patient requested or received treatment for ... an injury indicating that the person may be a victim of a criminal offense. This reporting obligation applies regardless of ... whether the patient wants the injuries to be reported." This policy was not followed. An example includes:

Patient #4 was a 26 year old female treated in the ED on 10/31/21, with final diagnoses of alleged assault, closed fracture of nasal bone, and laceration of oral cavity. A physician note for this encounter stated, "They have opted not to seek police help." There was no documentation that local law enforcement was notified of injuries indicating Patient #4 may have been a victim of a criminal offense.

The ED physician note in the record stated, "Incidentally the patient's husband was seen here last night with a boxer's fracture. Patient states that this was her sister-in-law who punched her and was not anything to do with her relationship with her current husband."

The CNO was interviewed on 4/28/22, beginning at 9:00 AM. When asked if ED staff was aware of mandated reporting responsibilities, she confirmed that they were aware.

The ED physician who saw Patient #4 on 10/31/21 was interviewed on 4/28/22, beginning at 11:20 AM. Patient #4's record was reviewed in his presence. When asked if this incident of alleged assault was reported to the police, he stated that "they were offered to have police involved and they declined." The ED physician stated he did not consider this incident a crime or domestic violence. The ED physician confirmed that he wrote a note in the patient's record.

The CAH failed to notify the local law enforcement agency that a patient requested treatment for an injury indicating that the person may be a victim of a crime in accordance with state law and CAH policy.

Based on observation and staff interview, it was determined the CAH failed to ensure patient care equipment was maintained. This had the potential for patient care equipment to malfunction or be unsafe for use when needed. Findings include:

A tour of the CAH's Emergency Department was conducted in the presence of the Quality Manager, the ED Charge Nurse, and the Assistant RN Manager on 4/27/22, beginning at 9:30 PM. During the tour, it was noted in the orthopedic cart, a cast saw had an outdated biomedical inspection tag with no inspection date.

The Manager of Patient Services was interviewed on 4/27/22, at 4:40 PM. He confirmed the absense of a current biomedical inspection tag on the cast saw and stated the cast saw was obsolete and would be replaced.

The CAH failed to ensure all patient care equipment was maintained.

Based on National Institute of Health Guidelines, medical record review, policy review, and staff interview, it was determined the CAH failed to ensure healthcare services were provided in accordance with appropriately written policies for 2 of 2 newborn patients (Patients #7 & #9) whose records were reviewed. This had the potential to result in avoidable, adverse patient outcomes. Findings include:

1. According to the National Institute of Health, accessed 5/02/22, "Respiratory distress in the newborn is recognized as one or more signs of increased work of breathing, such as tachypnea, nasal flaring, chest retractions, or grunting."

A CAH policy titled, "Immediate Newborn Care Urgent Protocol," revised 3/04/22, stated, "Any deviation of temperature, pulse, and/or respirations from normal limits warrants reassessment. Notify the primary care provider if the reassessment is outside normal limits."

A CAH policy titled, "Perinatal and Newborn Patient Care guideline," revised 1/04/21, stated, "Newborns notify parameters: ... If respiratory distress."

These policies were not followed. An example includes:

Patient #7 was born at the CAH on 1/07/22. His record for the day of birth was reviewed. Patient #7 was transferred to a larger hospital's NICU on 1/07/22.

Patient #7's record stated he was born on 1/07/22 at 5:10 AM. At 5:45 AM, the RN documented under the neurological assessment, "infant behavior depressed ... cry weak ... infant tone ... hypotonic [low muscle tone]." Under the respiratory assessment the RN documented, "grunting; periodic breathing [periods of no breathing] ... low RR [respiratory rate]." There was no documentation the physician was notified of the irregular respiratory assessment. There was no documentation interventions were performed when the respiratory distress was initially documented. The physician was not notified until a different RN requested an evaluation of Patient #7 at 7:40 AM, 1 hour and 55 minutes after the irregular assessment was initially documented.

An OB / Charge Nurse was interviewed on 4/28/22 beginning at 10:38 AM and Patient #7's record was reviewed in her presence. She was shown the abnormal respiratory assessment from 1/07/22 at 5:45 AM. When asked if she would notify a physician of the abnormal findings in Patient #7's record , she stated, "definitely." She looked in the record but was unable to find documentation the physician was notified of the abnormal assessment findings and interventions were performed before 7:40 AM.

An RN failed to ensure the physician was notified and interventions were performed for a newborn with respiratory distress.



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2. The CAH policy, "Perinatal and Newborn Patient Care Guideline," last reviewed by the CAH on 1/04/21, stated assessments for newborns were to include the following vital signs: Axillary temperature, Apical Heart rate, Respiratory rate, type of respirations, breath sounds, color, tone, activity state and capillary refill. The assessments were to be performed "After birth and every half hour, until infant is stable for 2 hrs [hours]. Q 4 hours x 24 hours [every 4 hours for 24 hours] Then q 8 hours & PRN [every 8 hours and as needed]."

The CAH policy was not followed. An example includes:

Patient #9 was a newborn male born at the CAH on 11/13/21 and transferred on 11/14/21 to a larger hospital's NICU for care of his tachypnea. His record documented his birth at 11:26 AM on 11/13/22. No vital signs were documented until 3:15 PM, more than 3 hours after his birth.

The OB Manager, an RN was interviewed on 4/27/22 at 5:00 PM. Patient #9's record was reviewed in her presence. She confirmed Patient #9 was not assessed according to CAH policy guidelines.

CAH staff did not follow their newborn assessment policy.

Based on policy review, medical record review, and staff interview, it was determined the facility failed to ensure physicians completed documentation on time for 1 of 2 newborn patients (Patient #7) whose records reviewed. This resulted in a discharge summary that was completed 20 days after the patient discharged. Findings include:

A facility policy titled, "Medical Record Completion," revised 2/04/22, stated discharge summaries were to be completed upon discharge, and the time frame for the documentation to be considered delinquent was 48 hours after discharge. This policy was not followed. An example includes:

Patient #7 was born at the facility on 1/07/22. His record for the day of birth was reviewed. He was transferred to a larger hospital's NICU on 1/07/22.

Patient #7's record included a discharge summary dated 1/07/22 and signed by the Physician. While the encounter date was 1/07/22, the note was not electronically signed until 1/27/22. It was unclear why the note was not completed until 20 days after Patient #7's discharge.

A Quality Management RN was interviewed on 4/26/22 beginning at 2:00 PM, and Patient #7's record was reviewed in her presence. She confirmed the discharge summary for Patient #7 was completed 20 days after discharge. She stated she wasn't sure why it was written 20 days late.

The facility failed to ensure physicians completed timely documentation.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure surgical instruments were processed according to policy for 1 of 2 instrument trays that were reprocessed and were observed by the surveyor. This created the possibility of surgical instruments being processed and sterilized incorrectly.

A facility policy titled, "Sterilization of Surgical/Procedural Items," approved 4/10/20 stated:

"Items must be kept moist during transport by adding one of the following:
a. a towel moistened with water
b. enzymatic pre-cleaner, foam spray or gel specifically intended for this use."

This policy was not followed. An example includes:

Observations of the surgical area were conducted on 4/27/22. An IP was present for the observations. The sterile processing department was observed beginning at 10:11 AM with the CST. There was a bowl of surgical instruments, which contained 1 clamp and 1 pair of scissors. The bowl contained a dried red/brown substance on the side and a small amount of a blue liquid in the bottom of the bowl. The clamp and scissors were observed to be dry at the time of the observation.

The CST was interviewed during the observations on 4/27/22 beginning at 10:11 AM. He stated the bowl of instruments, which included the clamp and scissors, was from the ED and he was waiting to reprocess them.

The IP who was present for the observations was interviewed on 4/27/22 at 3:57 PM. She confirmed the scissors and clamp were dry, and confirmed this did not match the facility's reprocessing policy.

The facility failed to ensure surgical instruments were processed according to policy.

Based on observation, facility document review, instructions for use, CDC infection control guidelines review, and staff interview, it was determined the CAH failed to maintain a sanitary environment for patients. This had the potential to place all patients receiving care at the facility at an increased risk for infection. Findings include:

1. The CDC website, https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/laundry.html, accessed 4/26/22 stated, "A temperature of at least 160°F (71°C) for a minimum of 25 minutes is commonly recommended for hot-water washing." This guideline was not followed.

A tour of the CAH's laundry room was conducted and interview with laundry services on 4/26/22, beginning at 9:45 AM, The Housekeeper in charge of laundry stated most of facility linens were sent out with a contracted service. She stated the only patient use linens cleaned in the facility were patient mammogram gowns. When asked what temperature the patient gowns are laundered at she stated, "between 140 and 160 degrees [Fahrenheit]". When asked for the temperature log for the washing machine she was unable to produce a current log. She stated the last time the temperature was documented was sometime in 2019. She stated she checked the temperature every morning however did not realize she needed to document it.

The facility's infection preventions was interviewed 4/28/22 beginning at 10:00 AM. She stated the facility followed CDC infection control guidance. She confirmed the temperatures for the water should be documented.

2. A tour of the Facility's off site medical clinics were conducted with the clinics infection control manager, clinic manager, and clinical supervisor on, 4/26/22 beginning at 2:00 PM. The clinics shared a building and were set up as a doctor's office setting. In one of the patient exam rooms there were 2 fabric chairs, when asked how the chairs were cleaned and disinfected after each patient, the clinical manager stated they used the Sanicloth disinfectant wipes. The instructions for use for the Sanicloth disinfectant wipes were reviewed, they stated for use on hard, nonporous surfaces. The clinics infection control manager confirmed the wipes should not be used on the chairs.

The facility failed to maintain a sanitary environment for patients.