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Based on staff interview, review of medical records, Medical Staff Bylaws, policies, and Idaho Statutes and Administrative Rules it was determined the hospital's Governing Body failed to provide sufficient oversight to ensure patients were admitted by and under the care of a physician as required in Idaho; nursing services were provided consistent with patients' needs, and an ongoing comprehensive infection control program was developed and implemented. This resulted in the potential for significant adverse patient outcomes. Findings include:

1. Refer to A064 as it relates to the Governing Body's failure to ensure medical staff bylaws were followed in order to provide quality healthcare to patients.

2. Refer to A065 as it relates to the failure of the Governing Body to ensure all patients were under the care of a physician as required by Idaho Statutes, Idaho Administrative Rules, and Medical Staff Bylaws.

3. Refer to A385 Condition of Participation of Nursing Services and associated standard level deficiencies as they relate to failure the Governing Body to ensure nursing services were provided and monitored consistent with patients' needs.

4. Refer to A747 Condition of Participation of Infection Control as it relates to the failure of the Governing Body to ensure a hospital-wide infection control program was developed and implemented.

These systemic negative practices seriously impede the ability of the hospital to provide safe and effective services.

Based on staff interview and review of medical records and Medical Staff Bylaws it was determined the hospital's governing body failed to ensure 1 of 4 Medicare patients (Patient #11) whose records were reviewed, was under the care of a physician. This resulted in an NP admitting, overseeing the care of, and discharging a Medicare patient without evidence of physician oversight. Findings include:

The hospital's Medical Staff Bylaws, undated, Article VII Section I: Exercise of Privileges stated, "In every case, a licensed physician will be responsible for the diagnosis and all medical care and treatment rendered to patients at this facility."

The Medical Staff Bylaws classified NPs as Allied Health Professionals. The bylaws stated at Article VIII Allied Health Professionals, "...participate directly in the management and care of patients under the general supervision or direction of an active or associate appointee of the Medical Staff." The same section further stated Allied Health Professionals could not "admit or discharge patients at the hospital."

The above Medical Staff Bylaws were not adhered to for Patient #11, as follows:

Patient #11 was a 51 year old male admitted to the facility on 10/09/14, related to schizoaffective disorder. The face sheet in his medical record stated his primary insurance was Medicare. The face sheet also listed the NP as the attending physician.

Additionally, his medical record included the following forms, signed by the NP, which did not included the signature of the supervisory physician:

- Initial Psychiatric Assessment dated 10/09/14.

-Admission Orders-"Admit to the services of Dr: {name of NP}, dated 10/09/14.

-Medical Consultation-history and physical dated 10/10/14.

-Progress Notes dated 10/10/14, 10/11/14, 10/12/14, 10, /13/14, 10/14/14 and 10/15/14.

-Master Treatment Plan dated 10/14/14.

Documentation of physician oversight of Patient #11's care was not found in his medical record.

During an interview on 10/17/14 beginning at 12:00 PM, the Psychiatrist who was also the Medical Director confirmed the NP admited patients and followed them through their hospitalization. He stated he indirectly provided oversight, as each patient is discussed during the Interdisciplinary Rounds on Wednesday mornings. He confirmed that he had no knowledge of Patient #11's admission to date. The Psychiatrist confirmed the bylaws specifically stated NP's cannot admit patients, and stated he would be able to adapt the bylaws to allow that activity.

During an interview on 10/17/14 beginning at 3:30 PM, the NP confirmed she admitted patients and followed them through to discharge. She stated the Medical Director provided indirect oversight, however, she was unable to provide documentation in the patients' records to support her statement.

The Governing Body did not ensure the care of Patient #11, whose primary insurance was Medicare, was under the care of a physician.




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Based on staff interview and review of medical records, Idaho Statutes and Administrative Code, and Medical Staff Bylaws, it was determined the hospital's governing body failed to provide the oversight necessary to ensure 2 of 12 patients (#9 and #11) whose records were reviewed, were admitted to the hospital by a licensed practioner permitted by the State to admit patients to hospitals. The lack of oversight resulted in patients being admitted by the NP. Findings include:

Idaho Code at 39-1301, includes a definition of a hospital. One section of the definition states a hospital is defined, in part, as a facility "...which is primarily engaged in providing, by or under the supervision of physicians, concentrated medical and nursing care ..." The same section of the Idaho Code defines a physician as "...an individual licensed to practice medicine and surgery by the Idaho state board of medicine or the Idaho state board of podiatry." The Idaho administrative rules for hospitals at IDAPA 16.03.14.200.01.h. state: "The {Medical Staff} bylaws shall specify that every patient be under the care of a physician licensed by the Idaho State Board of Medicine." IDAPA 16.03.14.200.01.m, states "Patients being treated by nonphysician practitioners shall be under the general care of a physician." NPs in Idaho are licensed consistent with IDAPA 23.01.01 Rules of the Idaho State Board of Nursing. Based on the above statutes and administrative rules, NPs may not independently admit patients to hospitals in Idaho.

The hospital's Medical Staff Bylaws, undated, Article VII Section I: Exercise of Privileges stated, "In every case, a licensed physician will be responsible for the diagnosis and all medical care and treatment rendered to patients at this facility."

The Medical Staff Bylaws classified NPs as Allied Health Professionals. The bylaws stated at Article VIII Allied Health Professionals, "...participate directly in the management and care of patients under the general supervision or direction of an active or associate appointee of the Medical Staff." The same section further stated Allied Health Professionals could not "admit or discharge patients at the hospital."

The above statutes, administrative rules, and Medical Staff Bylaws were not followed. Examples include:

1. Patient #9 was a 23 year old male admitted to the facility on 10/09/14, related to suicidal ideation. His discharge was ordered on 10/17/14.

Patient #9's record included a face sheet which listed the attending physician as the NP.

Additionally, his record included forms titled Discharge Orders, Discharge Medication Orders, and Discharge Instructions, dated 10/17/14. They each indicated the NP was Patient #9's physician. Patient #9's record did not include documentation by the psychiatrist.

During an interview on 10/17/14 beginning at 12:00 PM, the Psychiatrist who was also the Medical Director confirmed he was aware the NP admitted patients and continued to follow them through their hospitalization. He stated he indirectly provided oversight, as each patient is discussed during the Interdisciplinary Rounds on Wednesday mornings. Additionally, when asked if he knew the details of Patient #9's admission and course of treatment, he stated "No, I have never seen him." The Psychiatrist confirmed the Bylaws specifically stated NP's cannot admit patients.

During an interview on 10/17/14 beginning at 3:30 PM, the NP confirmed she admitted patients and followed them through to discharge. She stated the Medical Director provided indirect oversight, however, she was unable to provide documentation in the patients' records to support her statement.

The governing body did not ensure Patient #9 was admitted by a physician as required by Idaho Statutes, Idaho Administrative Rules, and hospital Medical Staff Bylaws.

2. Patient #11 was a 51 year old male admitted to the facility on 10/09/14, related to schizoaffective disorder.

Patient #11's medical record included a face sheet, which listed the attending physician as the NP.

Additionally, his medical record included forms, which the NP had signed, but there were no supervisory physician signatures as follows:

- Initial Psychiatric Assessment dated 10/09/14.

-Admission Orders-"Admit to the services of Dr: {name of NP}, dated 10/09/14.

-Medical Consultation-history and physical dated 10/10/14.

-Progress Notes dated 10/10/14, 10/11/14, 10/12/14, 10, /13/14, 10/14/14 and 10/15/14.

-Master Treatment Plan dated 10/14/14.

Documentation of physician oversight of Patient #11's care was not found in his medical record.

During an interview on 10/17/14 beginning at 12:00 PM, the Psychiatrist who was also the Medical Director confirmed the NP admited patients and followed them through their hospitalization. He stated he indirectly provided oversight, as each patient is discussed during the Interdisciplinary Rounds on Wednesday mornings. He confirmed that he had no knowledge of Patient #11's admission to date. The Psychiatrist confirmed the Bylaws specifically stated NP's could admit patients, and stated he would be able to adapt the bylaws to allow that activity.

During an interview on 10/17/14 beginning at 3:30 PM, the NP confirmed she admitted patients and followed them through to discharge. She stated the Medical Director provided indirect oversight, however, she was unable to provide documentation in the patients' records to support her statement.

The Governing Body did not ensure Patient #11 was admitted by a physician.

Based on review of hospital policies, medical records, and grievance information, and staff interviews, it was determined the hospital failed to ensure the hospital's grievance process included the expectation the hospital would provide written notice to patients that included required elements. This impacted 1 of 1 patient (#1) whose grievance was reviewed and had the potential to impact the clarity of resolution of grievances for all patients who filed grievances. Findings include:

On 10/14/14, surveyors requested to view the grievance log for all grievances filed from 3/01/13 until 10/14/14.

The grievance/complaint log was reviewed and included a grievance that was forwarded to the facility on 9/09/13, on behalf of Patient #1.

Patient #1 was a 26 year old female admitted to the hospital on 8/20/13, and discharged on 9/20/13. The grievance log contained a summary of Patient #1's hospital stay, however, there was no evidence of contact with Patient #1. Additionally, the log did not include documentation an investigation was conducted or if Patient #1 was informed regarding resolution of the grievance.

A "GRIEVANCE/COMPLAINTS" policy dated 4/2013, stated "The patient, or person filing the grievance complaint on behalf of the patient, will be informed of the investigation and the actions that will be taken to correct any identified problems. Such reports may be making orally by the Administrator or designee, within three working days of the filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the patient, and a copy will be secured in the office of the Administrator."

The CAO was interviewed on 10/16/14 at 2:00 PM. She stated the prior CAO should have taken responsibility for conducting an investigation and of responding to the complainant. She confirmed the grievance log for Patient #1 did not include documentation of a written response, and that Patient #1 or the complainant did not get a response.

The facility did not respond in writing to a patient grievance.

Based on staff interview and review of policies and clinical records, it was determined the hospital failed to ensure RN's appropriately monitored the care provided to patients to ensure their needs were met and practitioners were alerted to negative changes in patients' health status. This resulted in a lack of monitoring of medications administered, lack of assessment and reassessment of patients' conditions, and patients receiving more medications than ordered. Findings include:

1. Refer to A395 as it relates to the failure of the facility to ensure an RN provided sufficient supervision and oversight to ensure appropriate care was provided.

2. Refer to A457 as it relates to the failure of the facility to ensure nursing staff transcribed standing orders correctly.

These systemic failures significantly impede the ability of the hospital to provide nursing services of sufficient scope and quality.

Based on review of clinical records, hospital policies, and staff interviews, it was determined the facility failed to ensure an RN provided sufficient supervision and oversight to ensure appropriate patient care was provided for 7 of 12 patients (#3, #4, #6, #7, #9, #10, and #11) whose records were reviewed. This resulted in the potential for medication errors and deterioration in patients' medical conditions without interventions to occur. Findings include:

1. A facility policy, titled "Charting," revised 5/01/13, stated all observations, medications given, and services performed must be recorded in the patient's record. The follow up of all observations, medications given, and services performed must also be documented in the record. The policy also stated all incidents, accidents, or changes in the patient's condition must be recorded. It further stated, all pertinent information must be relayed to the attending provider or on-call provider, and documentation of all communication must be noted in the record.

A nursing services policy for nursing services titled "Daily Nursing Flow Sheets," revised 5/01/13, was reviewed. The policy stated the purpose of the nursing flow sheet was to provide a concise record of physical and psychological interventions and assessments. These policies were not followed. Examples include:

a. Patient #10 was a 41 year old male admitted on 10/10/14. His diagnoses included schizoaffective disorder (a combination of hallucinations or delusions, and mood disorder symptoms, such as mania or depression), bipolar disorder (mood swings that range from the lows of depression to the highs of mania), and alcohol and opiate detoxification.

Patient #10's record contained a vital sign flow sheet. The flow sheet included instructions for staff to notify the RN immediately if vital signs fall outside of the listed parameters, which were at the top of the flow sheet. A systolic blood pressure lower than 90 or greater than 160 or a diastolic blood pressure lower than 50 or greater than 100 were two of the parameters listed. The flow sheet instructions noted that abnormal vital signs were to be reassessed and documented on the back of the flow sheet. The physician was to be notified if the repeated vital signs were also out of parameter.

Patient #10's vital sign flow sheet contained the following entries:

- 10/12/14 at 10:20 AM, blood pressure of 86/49, (both out of parameter).
- 10/13/14 at 8:30 AM, blood pressure of 87/59, (systolic below parameter).
- 10/13/14 at 12:30 PM, blood pressure of 86/59, (systolic below parameter).

The vital sign flow sheet also had a column for the staff to indicate the RN was notified for vital signs that went outside the listed parameters. There was no documentation the RN was notified of the low blood pressure on 10/13/14 at 8:30 AM.

A facility policy titled "Nursing Process- Vital Signs," revised 4/24/2014, stated "A daily assessment of vital signs is completed on every patient, unless there is reason to complete the vital signs more frequently. The RN assesses the patients' vital signs and refers significant problems to the MD or mid-level provider for follow-up, evaluation, and treatment if needed."

Patient #10's vital sign flow sheet did not indicate his vital signs were reassessed. His record did not include documentation the physician or mid-level provider was notified regarding the low blood pressure measurements noted above on 10/12/14 and 10/13/14.

During an interview on 10/17/14 beginning at 10:55 AM, the CAO reviewed Patient #10's record. She confirmed the low blood pressure measurements, as well as, the failure to reassess according to policy. The CAO also confirmed Patient #10's record did not include documentation the physician or mid-level provider were notified.

Patient #10's low blood pressure was not reassessed, nor were the RN and physician notified as required by facility policies.

b. Patient #7 was a 65 year old female admitted 10/08/14. Her diagnoses included schizoaffective disorder, pneumonia, and sleep apnea.

On admission to the facility on 10/08/14, Patient #7's medical physician completed an H&P which included plans to continue antibiotic treatment, treatment with an inhaler every 6 hours, and oxygen at 2 liters per minute to ease shortness of breath for her diagnosis of pneumonia. The physician also included a plan for Patient #7 to use her CPAP machine (a small machine that supplies a constant and steady air pressure through the nose or mouth) while sleeping for her sleep apnea.

Patient #7's record also contained a physician order, dated 10/08/14, which stated she may use her own CPAP machine and to use oxygen at 2 liters by nasal cannula to keep oxygen saturation measurements greater than 93%.

- A nursing assessment by an RN, dated 10/09/14 at 12:40 PM, documented Patient #7's respiratory status was not within normal limits. A section titled "Physical Assessment," on the nursing flow sheet, contained a checked box which indicated abnormal findings, and that further information about the assessment would be in the progress notes/treatment plan. The progress notes did not include what was abnormal regarding Patient #7's respiratory status. The RN's entry did not include an assessment of breath sounds, or if Patient #7 was experiencing shortness of breath at the time of the assessment.

- A subsequent reassessment by an LPN, dated 10/09/14 at 1:20 AM, documented Patient #7 was not using the oxygen. Her oxygen saturation was measured at 92%. The LPN documented she assisted Patient #7 with resuming oxygen at 2 liters, but did not reassess her oxygen saturation or document if Patient #7's respiratory status had changed or improved.

- A nursing assessment by an RN, dated 10/10/14 at 12:30 PM, documented Patient #7's respiratory status was not within normal limits. A section titled "Physical Assessment," on the nursing flow sheet, contained a checked box which indicated abnormal findings, and that further information about the assessment would be in the progress notes/treatment plan. The progress notes did not include what was abnormal regarding Patient #7's respiratory status.

- A nursing assessment by an RN, dated 10/11/14 at 3:15 PM documented Patient #7's respiratory status was not within normal limits. A section titled "Physical Assessment," on the nursing flow sheet, contained a checked box which indicated abnormal findings, and that further information about the assessment would be in the progress notes/treatment plan. The progress notes did not include what was abnormal regarding Patient #7's respiratory status.

- A reassessment by an RN, dated 10/12/14 at 3:30 AM, documented Patient #7's status had no changes. At 3:40 AM the RN documented Patient #7 was very congested and treated with medication. The RN documented at 4:00 AM, Patient #7's oxygen measurement was 88% and she continued to have nasal congestion. Patient #7 was again placed on oxygen at 2 liters by mask, and not nasal cannula, as ordered. At 4:10 AM the RN documented Patient #7's oxygen measurement was 91%. There was no documentation by the RN of further interventions or that the physician or mid-level provider was notified of Patient #7's respiratory changes.

- A nursing assessment by an RN, dated 10/12/14 at 8:20 AM, documented Patient #7's respiratory status was not within normal limits. A section titled "Physical Assessment," on the nursing flow sheet, contained a checked box which indicated abnormal findings, and that further information about the assessment would be in the progress notes/treatment plan. The progress notes did not include what was abnormal regarding Patient #7's respiratory status.

- A reassessment by an LPN, dated 10/13/14 at 3:15 AM, documented Patient #7 was restless and making grunting noises both while awake and asleep. Patient #7 was documented as using her CPAP machine. The LPN also documented Patient #7 was coughing, producing mucus. The note included that staff would continue to monitor for changes in her status. There was no further reassessment by nursing staff during that shift which ended at 7:00 AM 10/11/14.

During an interview on 10/16/14 beginning at 3:30 PM, the CAO reviewed Patient #7's record. She confirmed Patient #7 was not reassessed by the nursing staff, per facility policy, after noting changes in her status. The CAO also confirmed Patient #7 was noted to receive oxygen by mask, rather than by nasal cannula as ordered. She stated she thought Patient #7 was placed back on oxygen per nasal cannula, and the LPN wrote mask by mistake.

Patient #7 was not further assessed by nursing staff according to her changing needs.

c. Patient #4's medical record documented a 58 year old female who was admitted to the facility on 9/01/13. Diagnoses included psychotic disorder and generalized anxiety disorder.

- Patient #4's record included a form titled "FACE-TO-FACE ASSESSMENT FOR THE USE OF HOLD AND RESTRAINT" unsigned, undated and untimed. It documented Patient #4's behaviors of increased agitation, anxiety, paranoia, non-redirectable behavior, yelling out, and medication non-compliance. It could not be determined when the assessment was completed.

- Patient #4's MAR noted Klonopin, a PRN medication for anxiety, was administered 10/15/13 at 5:00 PM. The nursing flow sheet dated 10/15/13, did not include documentation of her anxiety, or of a reassessment of her anxiety after the Klonopin was administered.

- Patient #4's MAR noted Klonopin was administered at 3:00 PM on 10/16/13. The nursing flow sheet dated 10/16/13, did not include documentation of her anxiety, or of a reassessment of her anxiety after the Klonopin was administered.

- Patient #4's MAR noted Prolixin, a PRN medication for psychosis/agitation, was administered 10/16/13 at 3:30 PM. The nursing flow sheet dated 10/16/13, did not include documentation of her agitation or psychosis, or of a reassessment after the Prolixin was administered.

During an interview on 10/16/14 beginning at 3:45 PM, the CAO reviewed Patient #4's record. She confirmed the nurse did not sign, date or time Patient #4's face-to-face assessment for the use of a hold and restraint. She also confirmed reassessments were not documented after PRN medication administration.

The facility failed to ensure an RN provided effective oversight of Patient #4's care.

d. Patient #3 was a 27 year old male admitted to the facility on 11/09/13, for psychiatric care related to schizophrenia and autism.

- A nursing flow sheet, dated 11/09/13, did not include day shift assessment, evening reassessment, or night shift assessment notes or nursing signatures. The nursing narrative for 11/09/13 included a single entry timed at 8:20 PM, "Pt was placed on 1:1 LOS after receiving IM injection while awake. Will continue to monitor Pt." The narrative charting from 11/09/13 from 8:20 PM until 11:00 AM 11/10/13, did not include further indication of his condition after the chemical restraint was administered. There was no documented nursing assessment of Patient #3 from the time of his admission at 5:50 PM on 11/09/13 through 11:00 AM on 11/10/13.

- A nursing flow sheet dated 11/10/13, did not include a pain assessment, or documentation of his bowel habits. The flow sheet included a section titled "PM Reassessment," which was blank. The section titled "Night Shift Assessment," included a single entry of "Pt is in his bed sleeping comfortably." The narrative section on the back of the flowsheet included an entry at 7:30 PM, "Pt had his mom and dad here to visit. Went well. Pt had 1:1 as ordered while awake. No negative behaviors."

- A nursing flow sheet dated 11/12/13, did not include documentation of his bowel habits, or of a reassessment after Haldol was administered at 9:15 PM.

- A nursing flow sheet dated 11/13/13, did not include documentation of his bowel habits, or reassessment after he received Klonopin at 7:00 PM, and Zyprexa at 7:10 PM for agitation. The flow sheet included a narrative note at 8:00 PM, which indicated Patient #3 continued to experience visual hallucinations, and he was given "multiple PRN medications for hallucinations and anxiety." There was no further documentation in Patient #3's record until the following day 11/14/13 at 9:45 AM.

- A nursing flow sheet dated 11/14/13, did not include documentation of his bowel habits, or of reassessment after Klonopin was administered at 4:15 PM on that date. His medication sheet documented he received a dose of Klonopin at 10:00 PM the same day for anxiety, however the nursing progress notes did not indicate he was experiencing increased anxiety. There was no entry in the progress notes that Patient #3 was reassessed after the above PRN medications were administered. The progress notes did not include an entry from 11/14/13 at 4:15 PM until the following day 11/15/13 at 7:45 AM.

- A nursing flow sheet dated 11/16/13, did not include documentation of a pain assessment, bowel habits and hydration status. His medication sheet indicated he received PRN Haldol on 11/16/13 at 11:00 AM, however, there was no indication of the reason for administration or of a reassessment in the progress notes. A progress note entry at 4:30 PM, noted PRN Zyprexa was administered for hallucinations and agitation, but there were no further entries in the progress notes until 11/16/13 at 12:30 PM.

- A nursing flow sheet dated 11/17/13, did not include documentation of a pain assessment, bowel habits and hydration status. His medication sheet indicated he received Klonopin on 11/17/13 at 9:00 PM, for agitation. However, the progress notes did not include documentation or reassessment after the PRN was administered.

- A nursing flow sheet dated 11/18/13, did not include documentation of a pain assessment, bowel habits and hydration status. His medication sheet indicated he received Klonopin on 11/18/13 at 9:00 PM, for agitation. However, the progress notes did not include documentation or of a reassessment after the PRN was administered. Patient #3's progress notes for 11/18/13 included brief narrative notes timed at 11:00 AM and 12:00 PM. There was no further documentation until 11/19/13 at 1:15 PM.

- A nursing flow sheet dated 11/19/13, did not include documentation of a pain assessment, bowel habits and hydration status. His medication sheet indicated he received Zyprexa on the same day at 11:25 AM, for agitation but the progress notes did not include documentation or of a reassessment after the prn was administered. His progress notes included a brief narrative note on 11/19/13 at 1:15 PM, and no further documentation until 11/20/14 at 11:45 AM.

- A nursing flow sheet dated 11/20/13, included a narrative note at 11:45 AM. The nurse documented Patient #3 had a flat affect, and was attending group meetings. The nurse further noted he denied suicidal ideation or hallucinations. The progress notes did not include further assessments or documentation until 11/21/14 at 9:20 AM. Patient #3's medication sheet for 11/20/13 indicated he received Haldol at 8:00 AM, Zyprexa at 8:00 AM, Klonopin at 9:00 AM, and again at 1:30 PM, and Zyprexa at 6:00 PM. There was no indication why the medications were administered, and there were no reassessments after these PRN medications were administered.

During an interview on 10/16/14 beginning at 4:30 PM, the VP of Operations reviewed Patient #3's record and confirmed the flow sheets did not include documentation by the nursing staff as related to pain, reassessments after PRN medications, and other assessment information that was left incomplete on the nursing flow sheets. She confirmed the medication sheets documented administration of PRN medications without further reassessments as to how effective the medications were.

An RN did not ensure Patient #3 received care and services consistent with his needs.

e. Patient #9 was a 23 year old male admitted to the facility on 10/09/14 for psychiatric care related to suicidal ideation.

- A nursing flow sheet dated 10/10/14, included a single narrative note at 11:00 AM. The note described Patient #9 as being suicidal with a plan. The nurse reported Patient #9 had increased paranoia, was avoidant with staff and peers and felt like he would explode with anger. There was no further narrative documentation that day to indicate if Patient #9 demonstrated improvement or if further interventions were implemented.

- A nursing flow sheet dated 10/11/14, included a single narrative note at 11:00 AM. The note included documentation that Patient #9 remained suicidal and depressed. There was no further narrative documentation that day by nursing staff.

- A nursing flow sheet dated 10/12/14, included a single narrative note at 2:45 PM. The note included documentation that Patient #9 denied suicidal ideation, hallucinations, and was cooperative with staff. There were no further entries for that day, however, his medication sheet indicated he requested multiple prn medications. The MAR noted he was administered PRN medications three times on 10/12/14; Ativan at 4:16 PM, and 8:25 PM, for anxiety, and Trazodone at 8:25 PM for sleep. There was no documentation of reassessment after the medications were administered.

- A nursing flow sheet dated 10/13/14, included a single narrative note at 1:40 PM. The note included documentation that Patient #9 denied suicidal ideation, hallucinations, and was oppositional with staff. There were no further entries for that day, however, his medication sheet indicated he received Ativan at 7:10 PM for anxiety. There was no documentation of reassessment after the PRN Ativan was administered.

- A nursing flow sheet dated 10/14/14, included a single narrative note at 1:55 PM. The note included documentation that Patient #9 was oppositional during his assessment, but did become more cooperative during the shift. There were no further entries for that day, however, his medication sheet indicated he received Ativan at 11:35 PM, and at 8:30 PM, for anxiety. There was no documentation of reassessments after the PRN Ativan doses were administered.

- A nursing flow sheet dated 10/15/14, included narrative entries at 10:00 AM and 12:00 PM. There were no further entries for that day, however, his medication sheet indicated he received multiple PRN medications. The MAR noted he was administered Ativan at 8:30 PM, and 8:50 PM, for anxiety, as well as, Trazodone at 8:50 PM for sleep. There was no documentation of reassessments after the Ativan and Trazodone doses were administered.

- A nursing flow sheet dated 10/16/14, included one narrative entry at 2:20 PM. His medication sheet indicated that on 10/16/14 he received Trazodone at 9:00 PM, and at 10:00 PM. There was no narrative to indicate a reassessment of Patient #9 was performed to evaluate the effectiveness of the PRN medications.

During an interview on 10/17/14 beginning at 3:30 PM, the CAO reviewed Patient #9's record and confirmed reassessments after PRN medications were not documented. Additionally, she stated each shift was to document in the narrative section regarding patients' assessments and activities during the shift, and confirmed the record did not indicate that was happening.

An RN did not ensure Patient #9 was assessed, reassessed, and monitored consistent with his needs.

2. The facility staffing shifts were 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM. A policy titled "Daily Nursing Flow Sheets", effective 5/01/13, stated the RN will complete the required 12 hour assessment each shift. It further stated the RN will delegate appropriate tasks and interventions, and will ensure that pertinent sections of the flow sheet are completed.

This policy was not followed. Examples include:

a. Patient #11 was a 51 year old male, admitted to the facility on 10/09/14. His diagnoses included schizoaffective and audio hallucinations.

- On a nursing flow sheet dated 10/16/14, an RN signed the bottom of the flow sheet at 12:00 PM. However, an additional reassessment was signed by an LPN at 9:15 PM, and 10/17/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- On a nursing flow sheet dated 10/12/14, an RN signed the bottom of the flow sheet at 9:25 AM, and reassessments were signed by an LPN at 9:30 PM, and 10/13/14 at 3:45 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- On a nursing flow sheet dated 10/10/14, an RN signed the bottom of the flow sheet at 11:30 AM, and a PM reassessment was signed by an LPN at 9:30 PM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

During an interview on 10/16/14 beginning at 3:30 PM, the CAO reviewed Patient #11's medical record and confirmed the assessments were not reviewed or co-signed by an RN as the policy indicated. She stated the RN must sign the patient assessment sheets every shift to indicate oversight.

The facility did not ensure RNs provided oversight of LPN patient assessments.



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b. Patient #6 was a 50 year old female admitted to the facility on 10/07/14 for psychiatric care related to suicidal ideation.

- A nursing flow sheet dated 10/07/14, included assessments at 11:35 PM and 10/08/14 at 5:00 AM. Both assessments were signed by an LPN. The admission assessment on 10/07/14 was signed by an LPN, and did not include an RN countersignature. Patient #6's record did not include documentation of RN oversight or assessments during the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/09/14, an RN signed the assessment at 12:40 PM, an LPN assessment was signed at 11:00 PM, and 10/10/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/12/14, an RN signed the assessment at 7:30 AM, an LPN signed the assessment at 10:00 PM and 10/13/14 at 3:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/13/14, an RN signed the assessment at 7:40 AM, an LPN signed the assessment 11:00 PM and on 10/14/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/14/14, an RN signed the assessment at 9:10 AM, an LPN signed the assessment at 11:00 PM and on 10/15/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

During an interview on 10/16/14 beginning at 3:30 PM, the CAO reviewed Patient #6's record and confirmed the flow sheets did not include an RN assessment each shift. She reviewed the policy, and stated an RN is to sign each shift assessment for all patients.

Patient #6's record did not include RN oversight as per facility policy.

c. Patient #9 was a 23 year old male admitted to the facility on 10/09/14 for psychiatric care related to suicidal ideation.

- A nursing flow sheet dated 10/13/14, an RN signed the assessment at 8:10 AM, and an LPN signed the assessment at 11:00 PM and on 10/14/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/14/14, an RN signed the assessment at 10:25 AM, and an LPN signed the assessment at 11:00 PM and on 10/15/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/15/14, an RN signed the assessment at 12:00 PM, and an LPN signed the assessment at 9:55 PM and on 10/16/14 at 6:00 AM. There was no documentation of RN assessments for each 12 hour shift.

- A nursing flow sheet dated 10/16/14, an RN signed the assessment at 12:00 PM, and an LPN signed the assessment at 11:00 PM and on 10/15/14 at 5:00 AM. There was no documentation of RN assessments for each 12 hour shift.

During an interview on 10/16/14 beginning at 3:30 PM, the CAO reviewed Patient #9's record and confirmed the flow sheets did not include an RN assessment each shift. She reviewed the policy, and stated an RN is to sign each shift assessment for all patients.

Patient #9's record did not include RN oversight as per facility policy.



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d. Patient #7 was a 65 year old female admitted 10/08/14. Her diagnoses included schizoaffective disorder, pneumonia, and sleep apnea (breathing periodically stops and starts while sleeping).

- A nursing flow sheet dated 10/09/14,an RN signed the assessment at 1:00 PM, and an LPN signed the assessment at 11:00 PM and on 10/10/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/12/14, an RN signed the assessment at 8:20 AM, and an LPN signed the assessment at 10:10 PM and on 10/13/14 at 3:15 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/13/14, an RN signed the assessment at 12:20 PM, and an LPN signed the assessment at 11:00 PM and on 10/14/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/14/14, an RN signed the assessment but did not include the time, and an LPN signed the assessment at 11:00 PM and on 10/15/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

During an interview on 10/16/14 beginning at 3:50 PM, the CAO reviewed Patient #7's record and confirmed the flow sheets did not include an RN assessment each shift. She reviewed the policy, and stated an RN is to sign each shift assessment for all patients.

Patient #7's record did not include RN oversight as per facility policy.

e. Patient #10 was a 41 year old male admitted on 10/10/14. His diagnoses included schizoaffective disorder (a combination of hallucinations or delusions, and mood disorder symptoms, such as mania or depression), bipolar disorder (mood swings that range from the lows of depression to the highs of mania), and alcohol and opiate detoxification.

- A nursing flow sheet dated 10/12/14, an RN signed the assessment at 9:05 AM, and an LPN signed the assessment at 11:00 PM and on 10/13/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

- A nursing flow sheet dated 10/13/14, an RN signed the assessment at 10:30 AM, and an LPN signed the assessment at 8:05 PM and on 10/14/14 at 5:00 AM. There was no documentation of an RN assessment on the 7:00 PM - 7:00 AM shift.

During an interview on 10/16/14 beginning at 3:50 PM, the CAO reviewed Patient #10's record and confirmed the flow sheets did not include an RN assessment each shift. She reviewed the policy, and stated an RN is to sign each shift assessment for all patients.

Patient #10's record did not include RN oversight as per facility policy.

Based on review of facility policies, record review, and staff interview, it was determined the facility failed to ensure nursing staff transcribed and processed standing orders correctly. This resulted in medication administration errors and transcription/documentation errors for 3 of 12 (#6, #9, and #10) patients whose records were reviewed. Findings include:

A facility policy "Standing Orders," revised 10/2014, noted that standing orders are to be discouraged. The policy further stated each item from the standing order list must be ordered in writing and be identified as an order from the approved standing order list.

During an interview on 10/17/14 beginning at 11:15 AM, the CAO described the facility's practice of using standing orders. She reviewed the hospital's standing orders. The CAO indicated patient records included a form titled "PHYSICIAN ORDERS AND MEDICATION RECONCILIATION," which she described as admission orders. The form included a section with a check box to indicate if standing orders were authorized. It also included space for the physician to state standing order medications that were not authorized.

During the same interview, the CAO also provided a copy of what she described as "Standing Orders." The printed paper included a title "Standing Order Medications." The form was undated and not signed. The form stated "The list below are the standing order medications for Safe Haven Hospital of Treasure Valley. Please note that these are not listed on the admission orders. If a patient needs an order for one of the standing order medications, you must also write an order on the Physician Orders."

The form included an example of how the nursing staff was to write the order. The example included instructions to write the selected order as a TORB (telephone order read back), followed by the practitioner's name and then the name of the nurse who was transcribing the order. During the interview with the CAO, she confirmed the standing orders were transcribed as telephone orders, although no telephone call from the practitioner would have occurred.

The standing order practices at the facility resulted in medication errors and the potential for additional errors to occur. Examples include:

1. Patient #9 was a 23 year old male, admitted on 10/09/14, for care related to suicidal ideation. His admission orders included a check mark beside the words "Standing Order Medications," indicating the use of standing orders were authorized.

Patient #9's admission orders included Trazodone, 50 mg to be taken each night as needed, for sleep. The record indicated the dose could be given once, but not to be repeated.

Patient #9's MAR documented Trazodone was administered on 10/12/14 at 10:25 PM, and on 10/16/14 at 8:00 PM.

A second MAR, with PRN medication administration documentation written in a different format, stated Patient #9 received Trazodone on 10/12/14 at 10:25 PM, 10/15/14 at 8:00 PM, and again at 8:50 PM, and 10/16/14 at 9:00 PM and 10:00 PM.

When the MAR and the additional MAR with PRN medication administration were reviewed together, the documentation indicated that on 10/15/14, Patient #9 recieved 2 doses of Trazodone - at 8:00 PM, and again at 8:50 PM. Additionally, on 10/16/14, Patient #9 recieved Trazodone at 8:00 PM, 9:00 PM, and at 10:00 PM, a total of 3 doses.

The hospital's standing orders stated Trazodone could be given PRN for insomnia and if the first dose was ineffective, a second dose could be given one hour after the first one. Patient #9's record did not include documentation the standing orders were implemented. His record included only the initial order for Trazadone 50 mg (once, not to be repeated).

The CAO reviewed Patient #9's record on 10/17/14 at 11:15, and confirmed the standing order for trazodone was not transcribed. She also confirmed the first MAR was incorrect and that since the standing order was not transcribed and authenticated, the extra doses of Trazodone on 10/15/14 and 10/16/14 were administered without an order.

Patient #9's record indicated standing orders were not transcribed and authenticated, therefore, he received medications without an order.

2. Patient #6 was a 50 year old female admitted to the facility on 10/07/14 for psychiatric care related to suicidal ideation. Her admission orders included a check mark beside the words "Standing Order Medications, with the Exception of Trazodone- it is scheduled."

Patient #6's admission orders dated 10/07/14, included Trazodone, 150 mg to be taken every night for sleep. It was written as a routine order, not as a prn.

However, Patient #6's medication tracking record indicated Trazodone 50 mg was transcribed from the standing orders list in error, and placed on the PRN medication list to be given nightly with an additional dose given if needed. The additional doses of Trazodone, if given, would result in a total of 250 mg nightly.

During an interview on 10/16/14 beginning at 3:30 PM, the CAO reviewed Patient #9's record and confirmed the standing orders for Trazodone were transcribed in error.

Trazodone was transcribed to Patient #6's medication sheet in error, creating the potential for the medication to be given without an order.



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3. Patient #10 was a 41 year old male admitted on 10/10/14. His diagnoses included schizoaffective disorder, bipolar disorder, and alcohol and opiate detoxification.

A pre-printed physician order form for opioid detoxification was in Patient #10's record. The form contained orders for medications to be administered as needed, if Patient #10 was observed with symptoms of withdrawal. The form was signed by the psychiatrist on 10/10/14 at 2:05 PM. It was also signed by the RN, but no date or time was documented.

The pre-printed orders contained an order for Trazodone with a possible error in how it was written. The order read "Trazodone 50 mg by mouth h.s. prn insomnia, M/Respirations x1 in 1 hour if the first dose is ineffective."

Patient #10's MAR included Trazodone, which was transcribed as "50 mg (PO) QHS PRN. May repeat X 1 (after) 1 (hour) if needed." The MAR indicated he received Trazadone 50 mg by mouth on 10/10/14 at 9:05 PM and again on 10/10/14 at 10:05 PM. His record did not include documentation to indicate the Tradodone order was clarified before transcription and administration.

During an interview on 10/17/14 beginning at 10:55 AM, the CAO reviewed Patient #10's record, including the pre-printed order form for opioid detoxification. She stated the word "Respirations" was a typo, and the order should have read as "May repeat once in 1 hour if the first dose is ineffective." Additionally, the CAO confirmed the record did not indicate the order was clarified before transcription or administration.

The facility failed to ensure orders were clearly written, and if not, the orders clarified by nursing staff prior to administration of the medication.

Based on staff interview and review of infection control documents and personnel files, it was determined the facility failed to ensure an active program for the prevention, control, and investigation of infections and communicable diseases, was developed and implemented. This resulted in the inability of the hospital to protect patients and personnel from infections and communicable diseases. Findings include:

1. Refer to A748 as it relates to the failure of the facility to appoint a trained infection control officer.

2. Refer to A749 as it relate to the failure of the facility to develop and implement a hospital-wide infection control program for the prevention, identification, investigation, and control of infections and communicable diseases of patients and personnel.

This systemic failure seriously impedes the ability of the hospital to provide care of sufficient scope and quality.

Based on staff interview and review of personnel files, it was determined the hospital failed to ensure the appointment of a trained infection control officer. This resulted in the failure of the facility to 1) to perform surveillance activities, 2) evaluate and trend results of infections occurring in the facility, and 3) implement education and training to staff. Findings include:

During an interview on 10/17/14 beginning at 3:00 PM the CAO identified the RN who was the infection control officer. The RN's personnel file was reviewed and contained no evidence of specialized training in infection control. During the same interview, the CAO confirmed the facility did not have a trained infection control officer.

The facility did not have a trained infection control officer.

Based on observation, staff interview, and infection control logs, it was determined the facility failed to ensure an active program was in place for the prevention, control, and investigation of infections and communicable diseases. This resulted in the failure to investigate, identify trends, and educate staff regarding infection control practices. Findings include:

The facility did not maintain an active program for the prevention, control, and investigation of infections and communicable diseases.

During an interview on 10/17/14 beginning at 2:10 PM the CAO was asked about the facility's infection control program. A request was made to view any staff training, infection logs, or QAPI data related to the infection control program for August and September of 2014. The CAO brought in an infection control log book which contained no data for August and September of 2014. The CAO was asked to bring the data she was working on for August and September. The CAO returned with blank audit tool forms which she stated were to be revised and used for the program eventually. The CAO confirmed nothing had been done with infection control since 8/01/14.

The hospital failed to develop and implement processes to protect patients and personnel from infections.