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Based on medical record review, policy review, observation, and staff interview, it was determined the CAH failed to ensure healthcare services were provided in accordance with appropriately written policies for 2 of 17 ED patients (#11 and #18) whose records were reviewed, and 1 of 1 clinic location whose sample medication storage was observed. This resulted in services not being furnished in a consistent manner, and had the potential to result in avoidable, adverse patient outcomes. Findings include:

Health care was not furnished in accordance with written CAH policies. Examples include:

1. A CAH policy "Referral and Transfer of Patients," approved 1/25/19, stated:

"The following must be fulfilled prior to transfer:

- The physician must sign a statement certifying that the medical benefits of the transfer outweigh the risks;

- The risks and benefits of the transfer must be explained to the patient or responsible person or legal guardian;

- The summary of the risks and benefits of transfer must be documented and signed by the patient or responsible person;"

"NURSE'S RESPONSIBILITY

- The transferring hospital should document its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer.

- Call the nursing department of the receiving hospital and give a verbal report on the patient."

This policy was not followed.

Patient #11 was a 77 year old female who was seen in the ED on 12/29/18, for an esophageal foreign airway obstruction. She was transferred to a nearby acute care hospital that same day.

Patient #11's medical record included an "EMERGENCY ROOM REPORT," dated 12/29/18, signed by the ED physician, which stated "Partial esophageal obstruction. Unable to tolerate solids but able to drink liquids. Protecting her airway well. Conversing normally. I did speak with the GI on call who was able and willing to see her. We will send her down to [city name] to be seen."

Patient #11's medical record did not include a signed physician statement certifying that the medical benefits of the transfer outweighed the risks. Her medical record did not include an explained summary of risks and benefits of the transfer. Patient #11's medical record did not include nursing documentation regarding her transfer.

The DON was interviewed on 3/06/19, beginning at 10:31 AM, and Patient #11's medical record was reviewed in her presence. She confirmed nursing staff did not document Patient #11's transfer. Additionally, the DON confirmed the ED physician who cared for Patient #11 did not document the explanation or summary of transfer risks and benefits.

The ED physician who cared for Patient #11 was interviewed via telephone on 3/06/19, beginning at 1:21 PM, and Patient #11's medical record was reviewed. He stated he was unsure if he completed transfer paperwork, risks, or benefits for Patient #11.

Patient #11's care was not furnished in accordance with written CAH policy.

2. A CAH policy "Suicide Precautions," approved 10/15/14, stated "Document on patient activity Q 15 min in Meditec or on the Suicide Observation Checklist if Meditec unavailable."

This policy was not followed.

Patient #18 was a 33 year old male who was seen in the ED on 1/16/19, for suicidal ideation and alcohol abuse. He was discharged home on 1/18/19.

Patient #18's medical record included an "EMERGENCY ROOM REPORT," dated 1/16/19, signed by the ED physician, which stated "Patient's depression sounds severe and his risk for suicide high. He will be placed on suicide precautions with a one-to-one sitter."

Patient #18's medical record included RN shift notes which documented Q 1 hour rounding for the duration of his stay, not Q 15 min rounding, as required by policy. Additionally, Patient #18's medical record did not include documentation he was provided a one-to-one sitter.

The DON was interviewed on 3/06/19, beginning at 10:31 AM, and Patient #18's medical record was reviewed in her presence. She confirmed nursing staff did not round on Patient #18 Q 15 min as required by CAH policy. Additionally, the DON confirmed a one-to-one sitter was not provided for Patient #18.

Patient #18's care was not furnished in accordance with written CAH policy.

3. A CAH policy "Sample Medications in Outpatient Clinical Setting," revised 10/01/16, stated "Clinical supervisor will assure that the inventoried medications are checked for expiration on a monthly basis and record in the log if they need to be removed."

A tour of the CAH's attached outpatient clinic was conducted in the presence of the Infection Control Officer on 3/04/19, beginning at 12:50 PM. During the tour, multiple expired patient medication samples were noted:

- 1 sample of Uloric (a medication for gout), expired 1/2017.

- 8 samples of Welchol (a medication for cholesterol and DM Type 2), expired 4/2018.

- 13 samples of Prilosec (a medication for GERD), expired 12/2018.

- 1 sample box of Miralax (a medication for constipation), expired 5/2018.

The Infection Control Officer was interviewed during the tour and confirmed the sample medications were expired and should have been removed.

Sample medications were not furnished in accordance with written CAH policy.

Based on policy review and staff interview, it was determined the CAH failed to ensure policies governing patient care services were consistently reviewed annually. This resulted in outdated policies and had the potential to impact quality and safety of patient care. Findings include:

A CAH policy, "Policy Development," last reviewed 1/23/18, stated "All clinical policies and procedures are reviewed a minimum every 12 months unless otherwise required by regulation."

CAH staff provided, upon request, a list of policies, including the last reviewed date. A sample of clinical policies that did not include documentation of annual review include:

* Administration of subcutaneous injections, last reviewed 7/08/14
* Admission of a labor patient, last reviewed 11/04/13
* Ambulance transport of an intubated patient, last reviewed 7/15/14
* Anesthesia coverage - pediatric, last reviewed 1/24/16
* Aspiration precautions, last reviewed 2/04/14
* Assessment - postpartum patient, last reviewed 12/03/13
* Breast milk storage, last reviewed 11/04/13
* Burn stabilization protocol, last reviewed 1/24/16
* Cardiac rehab - emergency response, last reviewed 3/10/14
* Cardiac rehab - equipment safety, last reviewed 2/10/14
* Carrying and transferring a newborn, last reviewed 11/04/13
* Cervical ripening with Dinoprostone (Cervidil), last reviewed 6/01/15
* Cesarean sections, scheduled & emergency, last reviewed 7/02/17
* Circumcision, last reviewed 11/04/13
* Cleaning and disinfecting of equipment and environment, last reviewed 10/08/13
* Continuous infusion - Lidocaine, last reviewed 3/24/14
* Critical values, last reviewed 8/17/15
* Cytotec (Misoprostal) administration, last reviewed 11/01/13
* Death of an infant (taking care of the grieving family), last reviewed 11/11/13
* Diet manual, last reviewed 8/30/13
* Dietary nourishment/supplements, last reviewed 8/30/13
* Discharge planning, last reviewed 7/15/14
* Epidural analgesia - narcotic and/or local, last reviewed 12/04/14
* Extended interval aminoglycoside dosing, last reviewed 9/24/13
* Fall prevention, last reviewed 12/30/15
* Fetal resuscitation - intrauterine, last reviewed 12/03/13
* Gavage tube feeding - infant, last reviewed 3/10/14
* Hemorrhage - antepartum, last reviewed 4/18/14
* Identification of a newborn, last reviewed 5/05/14
* Intraspinal narcotics, last reviewed 12/05/14
* IV Potassium guidelines, last reviewed 7/15/14
* Levophed (Norepinephrine), last reviewed 6/06/12
* Meconium aspiration of the newborn, last reviewed 4/18/14
* Pain injection service, last reviewed 9/05/14
* Patient rights and responsibilities, last reviewed 10/23/14
* Product recall, alert & safety hazard notification, last reviewed 9/28/12
* Radiology contrast reaction in CT/SMH, last reviewed 8/27/14
* Radiology ultrasound transvaginal probe, last reviewed 9/15/16
* Restraints, documentation and use, last reviewed 1/12/16
* Resuscitation of newborn at delivery, last reviewed 2/17/14
* Rubella vaccine - post partum, last reviewed 2/10/14
* Suicide precautions, last reviewed 10/15/14
* Traditional aminoglycoside dosing, last reviewed 9/24/13
* Vaginal exam, last reviewed 2/10/14
* Vasopressin infusion for refractory hyoptension, last reviewed 3/21/11
* Vitamin K use, last reviewed 10/02/12

The CNO was interviewed on 3/05/19 at 12:30 PM. She stated it was the intention of the CAH to review clinical policies annually and that some of the policies were outdated. During a second interview on 3/06/19 at 8:20 AM, she explained there were software issues, that prevented all of the review dates showing up in the system. She stated they were actively working to correct this issue.

Policies governing patient care services were not consistently reviewed annually.

Based on observation, job description review, infection control plan review, and staff interview, it was determined the CAH failed to ensure infection control oversight of outpatient surgical equipment for 1 of 1 outpatient clinics, where pre-cleaning of surgical equipment was observed. This had the potential for improper sanitation of outpatient surgical equipment. Findings include:

A tour of the CAH's attached outpatient clinic was conducted in the presence of the Infection Control Officer on 3/04/19, beginning at 12:39 PM. During the tour, surgical equipment was placed on a white towel in the soiled utility room.

When asked if surgical equipment was used for procedures in the outpatient clinic setting, the Infection Control Officer stated "yes." He stated outpatient clinic RNs and MAs were responsible for pre-cleaning of surgical equipment in the outpatient setting prior to transport to Central Sterile inside the CAH.

Job descriptions titled "Clinic Med Assist Cottonwood" and "Clinic RN Cottonwood" were reviewed. The job descriptions did not include duties pertaining to pre-cleaning of surgical equipment. The outpatient clinic employed 7 MAs and 6 RNs at the time of survey.

The "SMHC Infection Control Plan and Risk Assessment 2019" was reviewed and did not include the outpatient clinic. It could not be determined how the plan addressed oversight of infection control procedures in the outpatient clinic setting.

The Director of Clinic Operations and Director of Population Health were interviewed together on 3/05/19, beginning at 8:40 AM. When asked who was responsible for pre-cleaning of outpatient clinic surgical equipment, they stated the MAs and RNs. When asked if outpatient clinic MAs and RNs had documented competencies, evaluations, and training of pre-cleaning of surgical equipment, the Director of Population Health stated "no." When asked if pre-cleaning of surgical equipment was included in the outpatient clinic RNs' and MAs' job descriptions, the Director of Population Health stated "no." When asked if there was infection control oversight of the pre-cleaning of outpatient clinic surgical equipment, the Director of Population Health stated "no."

A clinic MA was interviewed on 3/05/19, beginning at 9:02 AM, and the pre-cleaning of surgical equipment was reviewed. When asked if 1 of her clinic job duties entailed the pre-cleaning of surgical equipment, she stated "yes." The MA stated she did not have a formal skills checklist or competency for this procedure. The MA stated she was unsure who provided infection control oversight of pre-cleaning of surgical equipment.

A clinic RN was interviewed on 3/05/19, beginning at 9:07 AM, and the pre-cleaning of surgical equipment was reviewed. When asked if 1 of her clinic job duties entailed the pre-cleaning of surgical equipment, she stated "yes." The RN stated she did not have a formal skills checklist or competency for this procedure. The RN stated she was unsure who provided infection control oversight of pre-cleaning of surgical equipment.

The CAH failed to ensure infection control oversight regarding pre-cleaning of outpatient surgical equipment.

Based on medical record review and staff interview, it was determined the CAH failed to ensure medical record documentation was complete for 11 of 35 patients (#1, #2, #7, #8, #10, #13, #17, #21, #23, #25, and #29) whose medical records were reviewed. This resulted in incomplete consent forms and EMTALA transfer forms, and a lack of clarity as to whether patients gave appropriate consent and whether patients were well informed about risks and benefits of transfer. Findings include:

1. Patient #25 was a 17 year old female admitted on 1/11/19 for a C-section. A "CONSENT FOR ANESTHESIA SERVICES," was signed by Patient #25 and a second individual. The date and time of the signatures were not included on the consent form. The relationship of the second individual who signed Patient #25's consent was not stated.

The Informatics RN was interviewed on 3/06/19 at 11:15 AM. She reviewed Patient #25's medical record and confirmed the anesthesia consent was incomplete.

Patient #25's consent form was incomplete.

2. Patient #2 was a 29 year old female admitted on 2/20/19 for a C-Section with tubal ligation. The "Surgical-Procedural Informed Consent" was signed by Patient #2 on 2/20/19. The time the consent was signed was not stated. A section of the consent required the patient or representative to circle whether she did or did not give consent to the use of blood products. Neither choice was circled.

The Informatics RN was interviewed on 3/06/19 at 11:10 AM. She reviewed Patient #2's medical record and confirmed the consent was incomplete.

Patient #2's consent form was incomplete.

3. Patient #23 was a 31 year old female admitted on 9/26/18 for labor and delivery. A "Surgical-Procedural Informed Consent" was signed by Patient #23 on 9/27/18 at 8:00 AM. A section of the consent required the patient or representative to circle whether she did or did not give consent to the use of blood products. Neither choice was circled.

The Informatics RN was interviewed on 3/06/19 at 11:15 AM. She reviewed Patient #23's record and confirmed the consent form was incomplete.

Patient #23's consent form was incomplete.

4. Patient #29 was a 38 year old female admitted to the CAH on 7/23/18 for a vaginal delivery. The form "PHYSICIAN PRESENCE NOTIFICATION" was signed and dated by Patient #25, but not timed.

The Informatics RN was interviewed on 3/06/19 at 11:20 AM. She reviewed Patient #25's medical record and confirmed the acknowledgment form did not include the time it was signed.

Patient #29's acknowledgement form was incomplete.



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5. Patient #1 was a 36 year old female who was admitted on 10/01/18, with a diagnosis of breech pregnancy.

Patient #1's medical record included a "Surgical-Procedural Informed Consent," dated 10/01/18, signed by Patient #1 and a physician. The form included the following section:

"I have been told how likely it is that I may need a blood transfusion (circle choice)
I do consent to the use of blood and blood products as deemed necessary.
I do not consent to the use of blood and blood products as deemed necessary."

This section was left blank. It was unclear what Patient #1's wishes were in regard to receiving blood and blood products.

The DON was interviewed on 3/06/19, beginning at 10:31 AM, and Patient #1's medical record was reviewed in her presence. She confirmed Patient #1's surgical consent was not complete.

Patient #1's medical record was not complete.

5. Patient #7 was a 62 year old female who was seen in the ED on 2/26/19, for appendicitis. She was transferred to a local acute care hospital later that same day.

Patient #7's medical record included a "TRANSFER OF PATIENT" form, dated 2/26/19, signed by the ED physician. The form included 2 sections titled "Telephone Order" and "I have explained the risks and benefits of transfer...MD Signature." These 2 sections were left blank. It could not be determined by whom or when the order to transfer Patient #7 was obtained. Additionally, it could not be determined if the ED physician explained the risks and benefits of the transfer to Patient #7.

The DON was interviewed on 3/06/19, beginning at 10:31 AM, and Patient #7's medical record was reviewed in her presence. She confirmed Patient #7's transfer form was incomplete.

Patient #7's medical record was not complete.

6. Patient #8 was a 69 year old female who was seen in the ED on 2/19/19, for a fractured tibia and fibula. She was transferred to a local acute care hospital later that same day.

Patient #8's medical record included a "TRANSFER OF PATIENT" form, dated 2/19/19, signed by the ED physician. The form included 2 sections titled "Telephone Order" and "I have explained the risks and benefits of transfer...MD Signature." These 2 sections were left blank. It could not be determined by whom or when the order to transfer Patient #8 was obtained. Additionally, it could not be determined if the ED physician explained the risks and benefits of the transfer to Patient #8.

The DON was interviewed on 3/06/19, beginning at 10:31 AM, and Patient #8's medical record was reviewed in her presence. She confirmed Patient #8's transfer form was incomplete.

Patient #8's medical record was not complete.

7. Patient #10 was a 28 year old female who was seen in the ED on 1/28/19, for pregnancy related complications. She was transferred to a local acute care hospital later that same day.

Patient #10's medical record included a "TRANSFER OF PATIENT" form, dated 1/28/19, signed by the ED physician. The form included 2 sections titled "Telephone Order" and "I have explained the risks and benefits of transfer...MD Signature." These 2 sections were left blank. It could not be determined by whom or when the order to transfer Patient #10 was obtained. Additionally, it could not be determined if the ED physician explained the risks and benefits of the transfer to Patient #10.

The DON was interviewed on 3/06/19, beginning at 10:31 AM, and Patient #10's medical record was reviewed in her presence. She confirmed Patient #10's transfer form was incomplete.

Patient #10's medical record was not complete.

8. Patient #13 was a 90 year old male who was seen in the ED on 2/03/19, for a NSTEMI. He was transferred to a local acute care hospital later that same day.

Patient #13's medical record included a "TRANSFER OF PATIENT" form, dated 2/03/19, signed by the ED physician. The form included 2 sections titled "Telephone Order" and "I have explained the risks and benefits of transfer...MD Signature." These 2 sections were left blank. It could not be determined by whom or when the order to transfer Patient #13 was obtained. Additionally, it could not be determined if the ED physician explained the risks and benefits of the transfer to Patient #13.

The DON was interviewed on 3/06/19, beginning at 10:31 AM, and Patient #13's medical record was reviewed in her presence. She confirmed Patient #13's transfer form was incomplete.

Patient #13's medical record was not complete.

9. Patient #17 was a 10 year old male who was seen in the ED on 1/15/19, for DKA. He was transferred to a local acute care hospital later that same day.

Patient #17's medical record included a "TRANSFER OF PATIENT" form, dated 1/25/19, signed by the ED physician. The form included 2 sections titled "Telephone Order" and "I have explained the risks and benefits of transfer...MD Signature." These 2 sections were left blank. It could not be determined by whom or when the order to transfer Patient #17 was obtained. Additionally, it could not be determined if the ED physician explained the risks and benefits of the transfer to Patient #17.

The DON was interviewed on 3/06/19, beginning at 10:31 AM, and Patient #17's medical record was reviewed in her presence. She confirmed Patient #17's transfer form was incomplete.

Patient #17's medical record was not complete.

10. Patient #21 was a 10 year old female who was seen in the ED on 11/13/18, for right lower quadrant pain. She was transferred to a local acute care hospital later that same day.

Patient #21's medical record included a "TRANSFER OF PATIENT" form, dated 11/13/18, signed by the ED physician. The form included 2 sections titled "Telephone Order" and "I have explained the risks and benefits of transfer...MD Signature." These 2 sections were left blank. It could not be determined by whom or when the order to transfer Patient #21 was obtained. Additionally, it could not be determined if the ED physician explained the risks and benefits of the transfer to Patient #21.

The DON was interviewed on 3/06/19, beginning at 10:31 AM, and Patient #21's medical record was reviewed in her presence. She confirmed Patient #21's transfer form was incomplete.

Patient #21's medical record was not complete.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure comprehensive POCs were developed for 2 of 4 swing bed patients (#31 and #33), whose records were reviewed. This resulted in a lack of direction to nursing staff. Findings include:

1. Patient #33 was a 92 year old male who was admitted to the CAH's swing bed program on 12/20/18. He was discharged to a skilled nursing facility on 1/03/19. His diagnoses included stroke, pneumonia, difficulty swallowing, and insulin dependent diabetes.

Patient #33's "Discharge Summary," dated 1/02/19, stated on admission, the patient had "word salad" and a flaccid right arm. The summary stated Patient #33's condition deteriorated and he had 3-4 days where he would not wake up. He was placed on IVs. The summary stated he developed pneumonia. The summary stated Patient #33 was probably terminal and had less than a month to live.

Patient #33's nursing POC, dated 12/20/18 at 2:48 PM, listed 2 problems. These were activity intolerance and impaired neurological status. The plans did not include nursing interventions to address the problems. The POC did not address Patient #33's diabetes, nutritional status, or pneumonia.

The DON was interviewed on 3/06/19 beginning at 9:05 AM. She stated Patient #33's POC was not complete.

The CAH failed to develop a comprehensive POC for Patient #33.

2. Patient #31 was an 87 year old female who was admitted to the CAH's swing bed program on 1/14/19. She was discharged to a skilled nursing facility on 2/28/19. Her diagnoses were stroke and frequent UTIs.

Patient #31's "Discharge Summary," dated 2/28/19, stated she had right sided weakness and could not walk on her own. A physician progress note, dated 1/27/19, stated Patient #31 had a draining fistula in her groin and subsequent nursing notes stated she had an odor and drainage from her vagina. A nursing progress note, dated 1/18/19 at 2:30 PM, stated Patient #31 had episodes of some regurgitation with all of her meals and had difficulty swallowing her food.

Patient #31's nursing POC, dated 1/14/19, listed activity intolerance as the only problem. The POC did not address Patient #33's swallowing or fistula issues.

The DON was interviewed on 3/06/19 beginning at 9:05 AM. She stated Patient #33's POC was not complete.

The CAH failed to develop a comprehensive POC for Patient #31.