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Based on review of medical records, admission packet review, and staff interview, it was determined the CAH failed to ensure written notice was provided that an MD/DO was not present in the CAH 24 hours a day/7 days a week to 20 of 20 inpatients (#s 1-19, and #37) whose records were reviewed. This had the potential to interfere with informed decision making about care. Findings include:

An admission packet was reviewed. There was no information included in the admission packet informing patients that an MD/DO was not present 24 hours a day/7 days a week.

Medical records were reviewed for Patient #s 1-19 and #37. The records did not include signed acknowledgements from the patient/representative stating that he/she understood that an MD/DO was not present during all hours services are furnished to him/her.

The CFO was interviewed on 3/06/17 at 2:00 PM. She stated information was posted in the ED that an MD/DO was not present 24/7. She stated she was not aware of any information that was provided in writing to patients.

The COO was interviewed on 3/06/17 at 2:05 PM. She confirmed notice was not provided in writing, other than the ED postings.

The CAH failed to ensure written notice was provided to patients informing them a MD/DO was not present in the CAH 24 hours a day/7 days a week.

Based on review of medical records, policies and procedures, Governing Body and MS bylaws and rules, and staff interview, it was determined the CAH's organizational structure was insufficient to ensure vital programs were defined, directed, and maintained. This resulted in a lack of leadership and direction to CAH staff. Findings include:

Refer to C-241 as it relates to the failure of the CAH to ensure the Governing Body specified, maintained, and monitored programs, policies, and bylaws.

The cumulative effect of these negative systemic issues seriously impeded the ability of the CAH to provide and document quality care.

Based on review of CAH policies, procedures, MS bylaws and rules, and staff interview, it was determined the Governing Body failed to ensure programs, policies, and bylaws were specified, maintained, and monitored, and included mid-level participation for all patients receiving care at the CAH. This resulted in a lack of leadership and direction to CAH staff. Findings include:

1. The "Medical Staff Rules" and the "Bylaws & Rules," dated 10/17/12 were reviewed.

a. The "Medical Staff Rules" stated 'The Bylaws Committee shall assure that the bylaws and rules are reviewed at least annually and updated as necessary." They were outdated as they had not been reviewed for over 4 years.

The MS rules addressed allied health professionals, such as NPs and PAs, who were contracted with the CAH. They did not address NPs and PAs who were employees.

The CFO was interviewed on 3/06/17 at 3:00 PM. She confirmed the MS bylaws and rules were outdated. During a second interview on 3/09/17 at 9:02 AM, she confirmed PA/NP employees were not addressed in the medical staff bylaws and rules.

The CAH failed to ensure MS bylaws addressed PA/NP employees and were not outdated.

b. The "Medical Staff Rules" and the "Bylaws & Rules," dated 10/17/12, did not address any requirement for mid-levels to participate in periodic review of medical records.

A full-time NP employee was interviewed on 3/09/17, at 8:30 AM. She stated she was not involved in review of medical records.

The Chief of Staff was interviewed on 3/08/17, at 8:18 AM. When asked about mid-level involvement in periodic review of medical records, he stated they were not involved, to his knowledge, except the PA's involvement with review of patient records related to trauma.

The CAH failed to ensure PAs and NPs routinely participated in periodic review of patients' health records.

2. The Governing Body failed to ensure annual review of policies as required by §485.635(a)(4). Examples of outdated policies include:

- Laboratory policies (multiple), dated 10/16/12
- Radiology policies (multiple), dated 10/16/12
- "Peer Review Policy," dated 1/01/11
- "Infection Prevention and Control Policy," dated 10/15/12
- "Interdisciplinary Care Planning," dated 10/17/12
- "Nurse Responsibilities of Patient Care," dated 2/09/15
- "Pain Assessment," dated 6/22/15
- "Transfer of Patients to Accepting Facility," dated 2/09/15
- "Patient Care Plans," dated 6/22/15
- "Pneumococcal Vaccine Standing Order," dated 6/22/15

The Policy Manager was interviewed on 3/08/17 at 9:10 AM. She confirmed policies were outdated. She stated they were in the process of getting them updated.

The CAH failed to ensure policies were reviewed annually.

3. "BOARD OF TRUSTEES MEETING MINUTES," dated 11/30/16, stated, on the advice of an attorney for an insurance program, the CAH voted to "dispense of" the Trustee (Governing Body) bylaws.

State of Idaho licensure rules (IDAPA 16.03.14.200.01) for hospitals of all types, required the maintenance of and compliance with Governing Body bylaws for items including membership of the Governing Body, meetings and minutes of such meetings, committees, appointments and reappointments to the Medical Staff, and items the bylaws must specify.

The meeting minutes did not state how the CAH would maintain compliance with the licensure rules if the bylaws were abolished.

The CEO was interviewed on 3/07/17 beginning at 2:35 PM. He stated the Board of Trustees abolished the CAH's Governing Body Bylaws on 11/30/16. He stated the hospital did not currently have Governing Body bylaws.

The Governing Body failed to maintain bylaws as required by state licensure rules.

4. The policy "Pharmacy and Therapeutics Committee," not dated, stated a committee which included a member of the MS, Director of Pharmacy, nursing staff member, and quality assurance/risk management member, would preside over policies and other matters and monitor the safe use of medications at the CAH. The policy stated the committee would meet at least 2 times per year.

The Pharmacist was interviewed on 3/09/17 beginning at 9:25 AM. He stated the Pharmacy and Therapeutics Committee had not met since at least 1/01/16.

The Governing Body failed to maintain a Pharmacy and Therapeutics Committee to oversee medication use.

5. Refer to C-270 as it relates to the failure of the CAH to ensure inclusion of mid-level practitioners in the development and review of policies, annual review of policies, a current ICO and regular IC committee meetings, a list of contracted services that described the nature and scope of CAH services, nursing services that met the needs of patients, and care plans that were developed and current.

6. Refer to C-300 as it relates to the failure of the CAH to ensure the clinical records system was maintained in accordance with current policies and procedures, clinical records were complete, accurate, readily accessible, and systematically organized, and H&Ps conducted by mid-level providers were countersigned by an MD/DO.

7. Refer to C-330 as it relates to the failure of the CAH to ensure a periodic evaluation and quality assurance program had been developed and implemented.

8. Refer to C-344 as it relates to the failure of the CAH to ensure written protocols were developed and implemented to address organ, tissue and eye procurement.

The cumulative effect of these negative systemic issues seriously impeded the ability of the CAH to provide and document quality care.


00023

Based on staff interview, it was determined the CAH failed to ensure the MD/DO periodically reviewed and signed the records of all inpatients cared for by mid-level practitioners. This impacted 2 of 2 patients (#6 and #13) whose records included H&Ps conducted by mid-level providers whose records were reviewed. Failure to sign records resulted in a lack of clarity regarding physician oversight of mid-level practitioners. It had the potential to negatively impact quality of patient care. Findings include:

The HIM Manager was interviewed on 3/07/17 at 8:30 AM. When asked if there were any co-authentication requirements for records regarding patients who were cared for by mid-level practitioners, she stated there were no co-authentication requirements.

A full-time NP employee was interviewed on 3/09/17 at 8:30 AM. She stated she could do H&Ps independently and there was no requirement for a physician's co-signature.

The Chief of Staff was interviewed on 3/08/17 at 8:18 AM. He stated he was a resource to NPs and PAs who had questions. He also stated he did not generally co-sign medical records of patients who received care from NPs and PAs.

Refer to C-305 as it related to failure of the CAH to ensure H&Ps conducted by mid-level providers were countersigned by an MD/DO for 2 of 2 patients (#6 and #13) whose records included H&Ps conducted by mid-level providers whose records were reviewed.

The CAH failed to ensure the MD/DO periodically reviewed and signed the records of all inpatients cared for by mid-level practitioners.

Based on review of policies, MS bylaws and rules, and staff interview, it was determined the CAH failed to ensure one or more of 5 mid-level practitioners (A-E) participated in the development, execution, and periodic review of all CAH's written policies governing the services the CAH furnishes. This resulted in policy development and review without mid-level input. Findings include:

The "Medical Staff Rules" and the "Bylaws & Rules," dated 10/17/12 were reviewed. There was no reference to PAs and NPs being involved in the development and review of written policies.

A sample of CAH policies were reviewed. With the exception of trauma policies, there were no signatures indicating PA/NP involvement in policies.

A full-time NP employee was interviewed on 3/09/17 at 8:30 AM. She stated she was not involved in policy development or review.

The Policy Manager was interviewed on 3/06/17 at 3:40 PM. When asked if mid-level practitioners were routinely involved in development and review of the CAH's policies, she stated they were not routinely involved. The exception was the Trauma Coordinator, a PA, who was involved in development and review of trauma specific policies only.

The Chief of Staff was interviewed on 3/08/17 at 8:18 AM. He confirmed the PA and NP were not involved in policy review, except for the PA's involvement in review of trauma policies.

The CAH failed to ensure the PA or NP members of the CAH's staff participated in the development, execution, and periodic review of the CAH's written policies governing the services the CAH furnishes.

Based on staff interview and review of CAH policies, a list of contracted services, IC meeting minutes, and medical records, it was determined the CAH failed to ensure inclusion of mid-level practitioners in the development and review of policies, annual review of policies, a current ICO and regular IC committee meetings, a list of contracted services that described the nature and scope of CAH services, nursing services that met the needs of patients, and care plans that were developed and current. Findings include:

1. Refer to C-272 as it relates to the failure of the CAH to include mid-level practitioners in the development and review of policies and to ensure policies were reviewed annually.

2. Refer to C-278 as it relates to the failure of the CAH to ensure a current ICO and regular IC committee meetings to support a facility-wide system for identifying, reporting, investigating, and controlling infections.

3. Refer to C-291 as it relates to a failure of the CAH to ensure the list of contracted services described the nature and scope of CAH services.

4. Refer to C-294 as it relates to the failure of the CAH to ensure nursing services met the needs of patients.

5. Refer to C-298 as it relates to the failure of the CAH to ensure nursing care plans were developed and kept current.

The cumulative effect of these negative systemic practices impeded the ability of the CAH to provide services of sufficient quality.

Based on staff interview and policy review, it was determined the CAH failed to ensure all policies were reviewed annually and that one or more of the CAH's 5 mid-level praticitioners (A-E) participated in the development, execution, and periodic review of all CAH's written policies. Failure to review policies annually had the potential to result in outdated policy information, which could impact patient care and health care processes. Findings include:

The CAH policies did not include documentation of annual review. Examples of outdated policies included:

- Laboratory policies (multiple), dated 10/16/12
- Radiology policies (multiple), dated 10/16/12
- "Peer Review Policy," dated 1/01/11
- "Infection Prevention and Control Policy," dated 10/15/12
- "Interdisciplinary Care Planning," dated 10/17/12
- "Nurse Responsibilities of Patient Care," dated 2/09/15
- "Pain Assessment," dated 6/22/15
- "Transfer of Patients to Accepting Facility," dated 2/09/15
- "Patient Care Plans," dated 6/22/15
- "Pneumococcal Vaccine Standing Order," dated 6/22/15

The Policy Manager was interviewed on 3/08/17, at 9:10 AM. She confirmed policies were outdated. She stated they were in the process of getting them updated.

Additionally, with the exception of trauma policies, there were no signatures indicating PA/NP involvement in policies.

A full-time NP employee was interviewed on 3/09/17, at 8:30 AM. She stated she was not involved in policy development or review.

The Policy Manager was interviewed on 3/06/17, at 3:40 PM. When asked if mid-level practitioners were routinely involved in development and review of the CAH's policies, she stated they were not involved routinely. She stated the PA, who was the Trauma Coordinator, was involved in trauma policies. There was no other involvement.

The Chief of Staff was interviewed on 3/08/17, at 8:18 AM. He confirmed the PA and NP were not involved in policy review, except for the PA's involvement in review of trauma policies.

The CAH failed to ensure policies were reviewed annually and routinely developed with the advice of one or more mid-level providers.

Based on CAH policy review, review of IC meeting minutes, and staff interview, it was determined the CAH failed to ensure a current ICO and regular IC committee meetings to support a facility-wide system for identifying, reporting, investigating, and controlling infections. This resulted in a lack of oversite of the CAH's IC program and had the potential to impact infection control standards for all patients provided services at the CAH. Findings include:

1. The policy, "Infection Prevention and Control Program," dated 10/15/12, was reviewed. The policy included the following information:

- "The Infection Control Professional(s) shall:
'Be responsible for the oversight of the Infection Prevention and Control Program as delegated by the Infection Control Committee'
'Develop, review, implement and evaluate policies and procedures governing infections and communicable diseases.'
'Develop and maintain a system for identifying, reporting, investigating and controlling infections and communicable diseases'
'Coordinate the Employee Health Program'
'Comply with the reporting of communicable diseases, outbreaks in the facility and HAI data to local and state agencies, as applicable.'
'Maintain a log of incidents related to infections and communicable diseases, including healthcare associated infections (HAIs) and infections identified through employee health services'"

There was no individual identified as the "Infection Control Professional" at the time of the survey.

The Nurse Educator was interviewed on 3/08/17, at 4:00 PM. She stated she did not know who the ICO was since the prior ICO left the previous month.

The CFO was interviewed on 3/09/17, at 8:00 AM. She stated the ICO position had not been re-assigned since departure of the last ICO.

The CAH did not have an assigned ICO to provide oversight of an Infection Control Program.

2. The policy, "Infection Control Committee Responsibilities," dated 10/15/2012, was reviewed. It included the following information:

- "The Infection Control Committee will be responsible for reviewing, revising and approving, no less than every year, all policies and procedures related to the infection surveillance, prevention, the Infection Control Program..."
- "The Infection Control Committee will meet no less than quarterly."
- "Meetings shall be documented in the Infection Control Committee minutes..."
- "The Infection Control Committee is multi-disciplinary and includes:
"Medical Staff Advisor (and other Physicians) as appointed by Chief of Staff for a 2-year term."
"Infection Control Practitioner"
"Representatives from: Administration, Nursing Service, Laboratory, Housekeeping, Pharmacy, and Extended Care representative."

Infection Control meeting minutes were requested for review. A folder was provided from 2016 to current. There were 2 documented meeting minutes in the folder, including 10/18/16 and 11/29/16. There was no documented physician representation at either meeting. There were no meeting minutes for 2017.

The CFO was interviewed on 3/09/17, at 8:00 AM. She stated she was not aware of any other meeting minutes or more current information.

The CAH did not have regular committee meetings in accordance with policy and did not have physician involvement.

Based on a review of a list of contracted services and staff interview, it was determined the CAH failed to ensure the list of contracted services described the nature and scope of CAH services. This resulted in an incomplete list of required information and had the potential to interfere with the access of contracted services. Findings include:

A CAH document "Contract/Purchased Services," dated 2017, included 2 columns: "Vendor Name" and "Department Name." Under each column was a documented vendor contract name and what corresponding CAH department it belonged to. The document did not document the nature and scope of the documented vendor contracts in either column.

The CFO was interviewed on 3/08/17, beginning at 3:15 PM, and the "Contract/Purchased Services" document was reviewed in her presence. She confirmed the document did not include the nature and scope of the listed vendor contracts.

The CAH failed to ensure the list of contracted services described the nature and scope of the services.

Based on review of medical records and staff interview, it was determined the CAH failed to ensure nursing services met the needs of 2 of 20 inpatients (#1 and #17) whose records were reviewed. This resulted in the failure to appropriately monitor and care for patients, consistently document patient information in the record, and report abnormal clinical findings to the physician. Findings include:

1. Patient #1 was a 78 year old female who was admitted on 4/24/16, with a diagnosis of AKI, CHF exacerbation, and UTI.

a. Patient #1's medical record included a laboratory results form, dated 4/24/16 at 7:27 AM. Patient #1 had a documented critical BNP (a heart failure laboratory test) value of 1040 pg/ml. The normal range for this test was documented as 5 to 100 pg/ml. Physician notification of Patient #1's critical laboratory value was not documented.

b. Patient #1's medical record included a laboratory results form, dated 4/25/16 at 7:15 AM. Patient #1 had a documented critical BNP value of 1110 pg/ml. The normal range for this test was documented as 5 to 100 pg/ml. Physician notification of Patient #1's critical laboratory value was not documented.

c. Patient #1's medical record included a vital signs form which documented 3 weight values from 4/25/16 to 4/26/16:

- 110 pounds on 4/25/16, at 4:05 AM
- 115 pounds on 4/25/16, at 2:22 PM
- 122.1 pounds on 4/26/16, at 9:44 AM

The nurse failed to ensure physician notification of Patient #1's 12 pound weight increase in 1 day was documented.

The Nurse Educator was interviewed on 3/08/17, beginning at 12:55 PM, and Patient #1's medical record was reviewed in her presence. She confirmed physician notification of Patient #1's critical laboratory values and increased weight were not documented.

Physician notification of Patient #1's abnormal clinical findings were not documented.

2. Patient #17 was a 78 year old female who was admitted on 2/23/16, with a diagnosis of hypertensive crisis, anxiety, nausea, vomiting, and pain.

a. Patient #17's medical record included nursing notes, dated 2/23/16 at 8:31 PM, and signed by the RN. The note documented "Will hold Labetalol [a medication for lowering blood pressure] for now and allow pt [sic] to sleep. B/P cuff wakes pt [sic] up." Physician notification of holding Patient #17's medication was not documented.

b. Patient #17's medical record included nursing notes, dated 2/24/16 at 2:00 AM, and signed by the RN. The note documented "Pt [sic] having more difficulty breathing than before, chest rising more forcefully with agonal-like breathing." Physician notification of Patient #17's change in condition was not documented.

c. Patient #17's medical record included nursing notes, dated 2/25/16 at 2:30 AM, signed by the CNA. The note documented "Blood Pressure. [sic] 218/108 Informed [sic] RN." The Mayo Clinic website, accessed 3/14/17, stated a normal blood pressure value for an adult is "top number lower than 120 mmHg" and "bottom number lower than 80 mmHg." Physician notification of Patient #17's elevated blood pressure was not documented.

RN N, who cared for Patient #17 on the above dates and times, was interviewed on 3/09/17, beginning at 9:15 AM, and Patient #17's medical record was reviewed in her presence. When asked if she documented physician notification regarding holding Patient #17's blood pressure medication, she stated no. When asked if she documented physician notification regarding Patient #17's change in respiratory condition, she stated no. When asked if she documented physician notification regarding the blood pressure reading the CNA obtained from Patient #17, she stated no.

The nurse failed to ensure physician notification of Patient #17's abnormal clinical findings were documented.

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to ensure nursing care plans were developed and kept current for 11 of 20 inpatients (#1, #2, #5, #6, #8, #9, #10, #11, #13, #14, and #16) whose records were reviewed. This had the potential to interfere with complete and consistent delivery of nursing care. Findings include:

The policy, "Patient Care Plans," dated 6/22/15, was reviewed. It included the following information:

- "Individual patient care plans will be developed and initiated within 24 hours of admission after the Registered Nurses or Licensed Practical Nurse initial assessment."

- "Care plans will include nursing care treatments required by the patient, medical treatment ordered for the patient, short-term and long-term goals, patient and family teaching plan both for hospital stay and discharge."

- "Psycho-social needs of the patient will be addressed on the nursing care plan."

- "Nursing care plans will be placed in the nursing patient's chart and will be updated as the need arises based on assessment findings."

- "Care plans will be updated as patient need arise. Documentation will include whether or not the patient has met the goals outlined based on assessment findings."

The policy was not followed as care plans were incomplete or missing. Examples include:

1. Patient #11 was a 65 year old male admitted on 4/04/16, for abdominal pain, alcohol withdrawal syndrome and COPD. He was discharged on 4/06/16.

There was no nursing care plan found in the medical record.

The Nurse Educator was interviewed on 3/08/17, at 4:38 PM. She reviewed Patient #11's record and stated she did not find a nursing care plan.

The CAH failed to ensure a care plan was developed for Patient #11.

2. Patient #10 was a 96 year old female was admitted on 8/29/16, after a CVA. She died on 8/31/16. The physician's "Admission H&P" indicated Patient #10 was in the hospital for palliative care.

There was no nursing care plan to address palliative care interventions.

The Nurse Educator was interviewed on 3/08/17, at 4:43 PM. She reviewed Patient #10's record and confirmed the nursing care plan was incomplete.

The CAH failed to ensure palliative care needs were included on Patient #10's care plan.

3. Patient #2 was a 31 year old female admitted on 7/11/16, for pancreatitis. She was discharged on 7/12/16.

The "Admission Nursing Assessment," dated 7/11/16, indicated Patient #2 was "underweight," "NPO," and a dietician was consulted.

A "Diet Order," dated 7/12/16, included orders for clear liquids.

The nursing care plan consisted of the following:

- "Pt's pain will be 5/10 or less with the use of PRN pain and nausea medication and reposition."

- "Pt's nausea will be controlled and vomiting prevented with the use of PRN nausea medications."

The care plan did not address Patient #2's nutritional status and dietary needs.

The Nurse Educator was interviewed on 3/08/17, at 2:30 PM. She reviewed Patient #2's medical record and confirmed the care plan appeared incomplete.

The CAH failed to ensure Patient #2's care plan addressed dietary and nutritional needs.

4. Patient #5 was an 84 year old male admitted on 9/09/16, and discharged on 9/10/16. His diagnoses included DM.

Nursing care plans addressed "RISK FOR FALLS," and "DECREASED CARDIAC OUTPUT." They did not address blood sugar monitoring requirements related to sliding scale insulin orders, dated 9/10/16.

The Nurse Educator was interviewed on 3/08/17, at 2:50 PM. She reviewed Patient #5's medical record and confirmed the care plan did not address Patient #5's diabetic status and need for blood glucose monitoring.

The CAH failed to ensure Patient #5's care plan addressed diabetic monitoring.

5. Patient #14 was a 77 year old female who was admitted on 6/17/16, related to a compression fracture. She was discharged home on 6/18/16.

Patient #14's care plan was "Pt's [sic] back pain will be tolerable or decreased on discharge. Pain will be controlled on pain medication on discharge."

The nursing care plan did not address an acceptable pain level for Patient #14. It did not indicate activity restrictions, which included the use of a walker according to nursing progress note, dated 6/18/16, at 10:36 AM.

The Nurse Educator was interviewed on 3/08/17, at 4:32 PM. She reviewed Patient #14's medical record and confirmed the nursing care plan was incomplete.

The CAH failed to ensure Patient #14's care plan addressed pain goals and activity restrictions.



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6. Patient #1 was a 78 year old female who was admitted on 4/24/16, with a diagnosis of AKI, CHF exacerbation, and UTI.

Upon review, the medical record provided by HIM staff did not contain a nursing care plan for Patient #1.

The Nurse Educator was interviewed on 3/08/17, beginning at 12:55 PM, and Patient #1's medical record was reviewed in her presence. She confirmed the medical record did not contain a nursing care plan.

The HIM Manager was interviewed on 3/08/17, beginning at 3:15 PM. Missing documents from Patient #1's medical record were requested for a second time, including the nursing care plan. The nursing care plan for Patient #1 was not provided by the close of the survey.

The CAH failed to ensure Patient #1 had a nursing care plan.

7. Patient #6 was a 62 year old female who was admitted on 1/31/17, with a diagnosis of pain, anemia, and wound care.

Upon review, the medical record provided by HIM did not contain a nursing care plan for Patient #6.

The Nurse Educator was interviewed on 3/08/17, beginning at 1:50 PM, and Patient #6's medical record was reviewed in her presence. She confirmed the medical record did not contain a nursing care plan.

The HIM Manager was interviewed on 3/08/17, beginning at 3:15 PM. Missing documents from Patient #6's medical record were requested for a second time, including the nursing care plan. The nursing care plan for Patient #6 was not provided by the close of the survey.

The CAH failed to ensure Patient #6 had a nursing care plan.

8. Patient #9 was a 75 year old male who was admitted on 1/13/17, for left hip pain.

Upon review, the medical record provided by HIM staff did not contain a nursing care plan for Patient #9.

The Nurse Educator was interviewed on 3/08/17, beginning at 1:45 PM, and Patient #9's medical record was reviewed in her presence. She confirmed the medical record did not contain a nursing care plan.

The HIM Manager was interviewed on 3/08/17, beginning at 3:15 PM. Missing documents from Patient #9's medical record were requested for a second time, including the nursing care plan. The nursing care plan for Patient #9 was not provided by the close of the survey.

The CAH failed to ensure Patient #9 had a nursing care plan.

9. Patient #13 was a 91 year old male who was admitted on 5/31/16, with a diagnosis of muscle weakness, cellulitis, and recurrent falls.

Upon review, the medical record provided by HIM staff did not contain a nursing care plan for Patient #13.

The Nurse Educator was interviewed on 3/08/17, beginning at 1:35 PM, and Patient #13's medical record was reviewed in her presence. She confirmed the medical record did not contain a nursing care plan.

The HIM Manager was interviewed on 3/08/17, beginning at 3:15 PM. Missing documents from Patient #13's medical record were requested for a second time, including the nursing care plan. The nursing care plan for Patient #13 was not provided by the close of the survey.

The CAH failed to ensure Patient #13 had a nursing care plan.



00023

10. Patient #8 was a 77 year old male who was admitted to the CAH on 12/09/16, for weakness, confusion, and cellulitis of his scrotum. He was moved to swing bed status on 12/13/16. A physician progress note, dated 12/12/16 at 7:51 AM, stated Patient #8 appeared to have had another stroke. It also stated he had pneumonia and the family refused to transfer him to an acute care hospital for treatment. A physician progress note, dated 12/14/16 at 11:31 AM, stated Patient #8's oxygen saturation level had dropped to 80 percent on room air at rest (normal 90% to 100%). Patient #8's condition continued to decline without aggressive treatment. He died on 12/18/16.

Patient #8's nursing POC was not dated. The plan was for "ACTIVITY INTOLERANCE." It directed nurses to assess Patient #8's vital signs, promote fluid balance, and to prepare him to safely take prescribed medications. The plan was not updated. Patient #8's respiratory problems, cellulitis, stroke, and impending death were not addressed on his POC.

Nurse N was interviewed on 3/09/17, at 11:50 AM. She stated Patient #8's POC did include all of his medical needs.

Nurse O was interviewed on 3/09/17, at 12:05 PM. She stated prior to March 2017, the CAH's EMR did not allow nurses to change the nursing POC after an initial POC was developed.

The CAH failed to develop a complete and updated POC for Patient #8.

11. Patient #16 was a 71 year old female who was admitted to the CAH on 10/26/16. Her H&P did not document an admitting diagnosis although it did state she had chronic lung disease. She was discharged on 10/30/16. Patient #16 did not have a documented nursing POC.

Nurse N was interviewed on 3/09/17, at 11:50 AM. She stated Patient #16 did not have a POC.

The CAH failed to develop a POC for Patient #16.

Based on staff interview, review of medical records, CAH policy review, and MS bylaws and rules review, it was determined the CAH failed to ensure the clinical records system was maintained in accordance with current policies and procedures, clinical records were complete, accurate, readily accessible, and systematically organized, and H&Ps conducted by mid-level providers were countersigned by an MD/DO. This resulted in incomplete, inaccurate medical records. Findings include:

1. Refer to C-301 as it relates to the failure of the CAH to ensure the clinical records system was maintained in accordance with current and relevant written policies and procedures.

2. Refer to C-302 as it relates to the failure of the CAH to ensure complete, accurate, and readily accessible, and systematically organized medical records were maintained.

3. Refer to C-305 as it relates to the failure of the CAH to ensure H&Ps conducted by mid-level providers were countersigned by an MD/DO.

The cumulative effect of these negative systemic practices impeded the ability of the CAH to maintain a quality and accessible medical record system.

Based on review of CAH policies and staff interview, it was determined the CAH failed to ensure the clinical records system was maintained in accordance with current and relevant written policies and procedures. This resulted in a lack of guidance to staff. Findings include:

Medical record policies and procedures were reviewed. They were found to be outdated. For example, a policy "Chart Order," dated 10/2012, provided guidance on the order of paper records, however the CAH was no longer using paper records.

There were no policies and procedures developed to address the CAH's EHR.

The HIM Manager was interviewed on 3/07/17 at 8:30 AM. She stated the CAH began converting to an EHR in 2015. She stated they were in process of developing policies related to the EHR but the current policies related to paper records. She confirmed the current policies and procedures were outdated.

The CAH failed to ensure the clinical records system was maintained in accordance with current and relevant written policies and procedures.

Based on medical record review and staff interview, it was determined the CAH failed to ensure complete, accurate, and readily accessible medical records were maintained for 15 of 20 inpatients (#1, #3, #4, #5, #6, #7, #8, #9, #13, #15, #16, #17, #18, #19, and #37) whose medical records were reviewed. It also failed to ensure systematic organization of medical records. These issues had the potential to interfere with the coordination and provision of patient care. Findings include:

1. The CAH failed to ensure medical records were readily accessible. Examples include:

a. The Release of Information Specialist was interviewed on 3/09/17, beginning at 8:19 AM. She stated Medical Records staff worked in 4 different EHR systems:

- Athena: Main EHR system originally developed for clinic use on 9/2015 and expanded for CAH use on 5/2016.

- Fortis: Main EHR system for CAH use until 10/2014 and now used for archived information, miscellaneous documents, and consents.

- Razor: Supplemental EHR for CAH use from 10/2014 to 9/2015.

- Sharpdesk: PDF-based program used to upload scanned documents to the Athena system.

The Release of Information Specialist stated there had been consistent problems creating a complete medical record from the 4 EHR systems. She stated she was the designated Medical Records employee to print medical records, however she did not have formal training for this task. The Release of Information Specialist stated she had previously not attempted to print an entire, legal medical record prior to the survey and confirmed there was no policy, procedure, or algorithm for Medical Record staff to follow in this task. She stated there was no overall process to standardize medical record printing.

b. The Nurse Educator was interviewed on 3/08/17 at 4:30 PM. She stated staff could not print medical records stored in "Athena."

c. The HIM Manager was interviewed on 3/09/17 at 11:00 AM. She stated she had not received training in Athena as the hospital was a pilot hospital and "we are training them."

The CAH failed to ensure medical records were readily accessible.

2. Medical records were not systematically organized.

The HIM Manager was interviewed on 3/07/17 at 8:30 AM. She stated they began converting to an EHR in 2015. She stated she was the only employee in the Medical Records Department who dealt with inpatient records. When asked about the process for ensuring the record was complete after patients were discharged, she stated she looked through the record to ensure signatures, dates, H&P, progress notes, ER notes, discharge notes, etc., were present. When asked to see the audit tool she used, she stated she did not use any formal tool or checklist. When asked the policy and procedure to notify providers of chart deficiencies, she stated she sometimes texted the provider and sometimes talked to them to let them know. There was no specific policy or procedure.

The CAH failed to ensure medical records were systematically organized.

3. The CAH failed to ensure medical record entries were complete and accurate. Examples include:

a. Patient #6 was a 62 year old female who was admitted on 1/31/17, with a diagnosis of pain, anemia, and wound care.

i. Patient #6's medical record included an "INPATIENT CERTIFICATION," signed by the physician. The physician's signature was not timed or dated.

ii. Patient #6's medical record included an "Advance Beneficiary Notice (ABN)," dated 2/04/17, and signed by the patient. The form included "Option 1. YES. I want to receive these items or services" with an accompanying checkbox. Additionally, the form included "Option 2. NO. I have decided not to receive these items or services" with an accompanying checkbox. Both checkboxes were left blank.

iii. Patient #6's medical record included an "Admission Summary Sheet," dated 1/31/17, signed by the RN. The form included a section at the bottom of the page titled "ASSIGNMENT OF INSURANCE BENEFITS." This section stated "I the undersigned acknowledge that I have received a copy of my patient rights and a copy of the HIPAA notice of privacy practices." This section included Patient #6's signature, however the signature was not timed or dated.

iv. Patient #6's medical record included a second "Admission Summary Sheet," dated 2/04/17, signed by the RN. The form included a section at the bottom of the page titled "ASSIGNMENT OF INSURANCE BENEFITS." This section stated "I the undersigned acknowledge that I have received a copy of my patient rights and a copy of the HIPAA notice of privacy practices." This section included Patient #6's signature, however the signature was not timed or dated.

v. Patient #6's medical record included a "HISTORY AND PHYSICAL ADDENDUM," dated 2/04/17. The bottom of the form included the physician's signature, however the signature was not timed or dated.

vi. Patient #6's medical record included a "Nutritional Risk Screening," dated 2/01/17, signed by the RN. The bottom of the form included a section to document the date, time, and staff initials of the employee who faxed the completed form to the RD. This section was left blank.

The Nurse Educator was interviewed on 3/08/17, beginning at 1:50 PM, and Patient #6's medical record was reviewed in her presence. She confirmed the missing documentation from Patient #6's medical record.

The CAH failed to ensure Patient #6's record was complete.

b. Patient #17 was a 78 year old female who was admitted on 2/23/16, with a diagnosis of hypertensive crisis, anxiety, nausea, vomiting, and pain.

i. Patient #17's medical record included a "Consent to Treatment Form," dated 2/23/16, signed by the RN. The consent was signed by Patient #17's spouse, however, the signature was not timed or dated.

ii. Patient #17's medical record included "PROGRESS NOTES," undated, and unsigned. The notes had a total of 5 entries documented on the following times:

- 5:50 AM
- 5:56 AM
- 6:32 AM
- 6:38 AM
- 7:14 AM

The 5 entries did not document a signature or date.

iii. Patient #17's medical record included a "PHYSICIAN'S ORDER SHEET" with a verbal order dated 2/29/16, and signed by the RN. The verbal order was not signed, dated, or timed by the physician.

iv. Patient #17's medical record included a second "PHYSICIAN'S ORDER SHEET" with a verbal order dated 3/18/16, and signed by the RN. The verbal order was not signed, dated, or timed by the physician.

v. Patient #17's medical record included a "Nutritional Risk Screening," undated, and unsigned. The bottom of the form included a section to document the date, time, and staff initials of the employee who faxed the completed form to the RD. This section was left blank.

vi. Patient #17's medical record included "Interdisciplinary Swing Bed Conference" forms, dated 3/02/16 and 3/09/16, and signed by the nurses, therapists, and administration participating in her swing bed POC. The forms included a section titled "RESTRAINT REVIEW: CHEMICAL." Under this section was documented "Librium BID." However, Patient #17's MAR did not list Librium as a chemical restraint. Librium was listed as a BID scheduled medication for anxiety.

RN N was interviewed on 3/09/17, beginning at 9:15 PM, and Patient #17's medical record was reviewed in her presence. She confirmed the missing and inaccurate documentation from Patient #17's medical record.

The CAH failed to ensure Patient #17's record was complete and accurate.

c. Patient #1 was a 78 year old female who was admitted on 4/24/16, with a diagnosis of AKI, CHF exacerbation, and UTI.

i. Patient #1's medical record included an "Admission Summary Sheet," dated 4/24/16, and signed by the RN. The form included a section at the bottom of the page titled "ASSIGNMENT OF INSURANCE BENEFITS." This section stated "I the undersigned acknowledge that I have received a copy of my patient rights and a copy of the HIPAA notice of privacy practices." This section included Patient #1's signature, however the signature was not timed or dated.

ii. Patient #1's medical record included a "LINCARE" form titled "Detailed written order [sic]." The form was a pre-printed order sheet for home oxygen DME. The bottom of the form included a verbal order signed and dated by the RN. The verbal order was not signed, dated, or timed by the physician.

iii. Patient #1's medical record included a form, untitled, undated, and unsigned which included her allergies. Her allergies were documented as:

- Demerol - Status : Verified
- Iodinated Contrast Media - Status : Verified
- adhesive [sic] - Status : Verified

Her medical record also included a "PHYSICIAN'S ORDER SHEET," dated 4/24/16, signed by the NP. The order sheet included "allergies - Demerol." The order sheet did not include Patient #1's allergies to iodinated contrast media or adhesive.

iv. Patient #1's medical record included a "Nutritional Risk Screening," dated 4/27/16, signed by the RN. The bottom of the form included a section to document the date, time, and staff initials of the employee who faxed the completed form to the RD. This section was left blank.

The Nurse Educator was interviewed on 3/08/17, beginning at 12:55 PM, and Patient #1's medical record was reviewed in her presence. She confirmed the missing and inaccurate documentation from Patient #1's medical record.

The CAH failed to ensure Patient #1's record was complete and accurate.

d. Patient #4 was a 69 year old female who was admitted on 7/17/16, with a diagnosis of constipation, right arm pain, pancreatitis, and acute hyponatremia (low blood levels of sodium).

i. Patient #4's medical record included a "PHYSICIAN'S ORDER SHEET," dated 7/17/16, signed by the physician. The order sheet included "All [sic]: cod [sic], Demerol, Lodine, Vicodin."

Her medical record also included a "PATIENT TRANSFER FORM," dated 7/20/16, signed by the physician. The transfer form included "(State all allergies if any) Lodine, Vicoden [sic], demerol [sic]."

Additionally, her medical record included a form untitled, undated, and unsigned which included her allergies. Her allergies were documented as:

- DEMEROL
- LODINE

Patient #4's medical record also included a second form untitled, undated, and unsigned which included her allergies. Her allergies were documented as:

- BEE VENOM (HONEY BEE)
- DEMEROL
- LODINE

These 4 forms did not document consistent and accurate patient allergy information.

ii. Patient #4's medical record included an "INPATIENT CERTIFICATION," signed by the physician. The physician's signature was not timed or dated.

iii. Patient #4's medical record included an "Admission Summary Sheet," dated 7/19/16, signed by the RN. The form included a section at the bottom of the page titled "ASSIGNMENT OF INSURANCE BENEFITS." This section stated "I the undersigned acknowledge that I have received a copy of my patient rights and a copy of the HIPAA notice of privacy practices." This section included Patient #4's signature, however the signature was not timed or dated.

iv. Patient #4's medical record included a "Nutritional Risk Screening," dated 7/17/16, signed by the RN. The bottom of the form included a section to document the date, time, and staff initials of the employee who faxed the completed form to the RD. This section was left blank.

The Nurse Educator was interviewed on 3/08/17, beginning at 1:20 PM, and Patient #4's medical record was reviewed in her presence. She confirmed the missing and inaccurate documentation from Patient #4's medical record.

The CAH failed to ensure Patient #4's record was complete and accurate.

e. Patient #13 was a 91 year old male who was admitted on 5/31/16, with a diagnosis of muscle weakness, cellulitis, and recurrent falls.

i. Patient #13's medical record included a "Nutritional Risk Screening," undated, and unsigned. The bottom of the form included a section to document the date, time, and staff initials of the employee who faxed the completed form to the RD. This section was left blank.

ii. Patient #13's medical record included an "PATIENT CERTIFICATION," signed by the physician. The physician's signature was not timed or dated.

iii. Patient #13's medical record included an "Admission Summary Sheet," undated, and unsigned. The form included a section at the bottom of the page titled "ASSIGNMENT OF INSURANCE BENEFITS." This section stated "I the undersigned acknowledge that I have received a copy of my patient rights and a copy of the HIPAA notice of privacy practices." This section included Patient #13's wife's signature, however the signature was not timed or dated.

The Nurse Educator was interviewed on 3/08/17, beginning at 1:35 PM, and Patient #13's medical record was reviewed in her presence. She confirmed the missing documentation from Patient #13's medical record.

The CAH failed to ensure Patient #13's record was complete.

f. Patient #9 was a 75 year old male who was admitted on 1/13/17, with a diagnosis of left hip pain.

Patient #9's medical record included an "Admission Summary Sheet," dated 1/14/17, signed by the RN. The form included a section at the bottom of the page titled "ASSIGNMENT OF INSURANCE BENEFITS." This section stated "I the undersigned acknowledge that I have received a copy of my patient rights and a copy of the HIPAA notice of privacy practices." This section included Patient #9's signature, however the signature was not timed or dated.

The Nurse Educator was interviewed on 3/08/17, beginning at 1:45 PM, and Patient #9's medical record was reviewed in her presence. She confirmed the missing documentation from Patient #9's medical record.

The CAH failed to ensure Patient #9's record was complete.

g. Patient #18 was an 87 year old male who was admitted on 9/02/16, with a diagnosis of right hip fracture rehabilitation, COPD, HTN, and depression.

Patient #18's medical record included an "Admission Summary Sheet," dated 9/02/16, signed by the RN. The form included a section at the bottom of the page titled "ASSIGNMENT OF INSURANCE BENEFITS." This section stated "I the undersigned acknowledge that I have received a copy of my patient rights and a copy of the HIPAA notice of privacy practices." This section included Patient #18's signature, however the signature was not timed or dated.

The Nurse Educator was interviewed on 3/08/17, beginning at 2:03 PM, and Patient #18's medical record was reviewed in her presence. She confirmed the missing documentation from Patient #18's medical record.

The CAH failed to ensure Patient #18's record was complete.

h. Patient #19 was a 98 year old male who was admitted on 11/30/16, with a diagnosis of right hip replacement surgery rehabilitation.

Patient #19's medical record included an "Admission Summary Sheet," dated 12/01/16, signed by the RN. The form included a section at the bottom of the page titled "ASSIGNMENT OF INSURANCE BENEFITS." This section stated "I the undersigned acknowledge that I have received a copy of my patient rights and a copy of the HIPAA notice of privacy practices." This section included Patient #19's signature, however the signature was not timed or dated.

The Nurse Educator was interviewed on 3/08/17, beginning at 2:14 PM, and Patient #19's medical record was reviewed in her presence. She confirmed the missing documentation from Patient #19's medical record.

The CAH failed to ensure Patient #19's record was complete.

i. Patient #3 was an 89 year old female admitted to the CAH on 7/13/16, for pneumonia and discharged on 7/16/16.

The admission consent was not found in Patient #3's medical record.

The Nurse Educator was interviewed on 3/08/17, at 2:45 PM. She reviewed Patient #3's record and confirmed the admission consent was missing.

The CAH failed to ensure Patient #3's record was complete.

j. Patient #5 was an 84 year old male admitted on 9/09/16, related to a hypotensive episode, muscle weakness, and DM. He was discharged on 9/10/16. An H&P was not found in Patient #5's medical record.

The Nurse Educator was interviewed on 3/08/17, at 2:50 PM. She reviewed Patient #5's medical record and confirmed the H&P was missing.

The CAH failed to ensure Patient #5's record was complete.

k. Patient #7 was a 78 year old male who was admitted to a swing bed on 11/16/16, and died on 11/22/16. There was no discharge summary or death summary found in Patient #7's medical record.

The Nurse Educator was interviewed on 3/08/17, at 3:00 PM. She reviewed Patient #7's medical record. She stated there should have been a death summary and she did not see one included in the medical record.

The CAH failed to ensure Patient #7's record was complete.

l. Patient #15 was a 90 year old male who was admitted on 9/30/16, with weakness, bradycardia, CHF, and DM. He was transferred to another acute care facility on 10/01/16. The discharge summary was not signed by the provider.

The Nurse Educator was interviewed on 3/08/17, at 4:47 PM. She reviewed Patient #15's medical record and confirmed the discharge summary was incomplete.

The CAH failed to ensure Patient #15's record was complete.



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m. Patient #8 was a 77 year old male who was admitted to the CAH on 12/09/16, for weakness, confusion, and cellulitis. He died on 12/18/16.

Personal care, such as bathing, oral care, and perineal care, were not documented for Patient #8 during his stay.

Nurse D was interviewed on 3/08/17, beginning at 9:45 AM. She confirmed personal care was not documented for Patient #8. She stated CNAs provided and documented patients' personal care. She stated nurses provided personal care as well, but they did not document that care.

Staff failed to document personal care for Patient #8.

n. Patient #37 was a 96 year old male who was admitted for pneumonia on 3/05/17, at 6:06 PM. He was discharged on 3/08/17.

Personal care was documented 3 times during Patient #37's stay as follows:

- On 3/05/17 at 8:03 PM, the CNA documented Patient #37 refused oral care, was independent in perineal care, and was repositioned "...as much as he allows."

- On 3/07/17 at 12:12 AM, the CNA documented Patient #37 was turned "...as much as tolerated." A bath, oral care, and perineal care were not documented.

- On 3/08/17 at 3:23 AM, the CNA documented Patient #37 received a bed bath, oral care, perineal care, and was turned as he allowed. Except for the above 3 times in 4 days, there was no documentation that personal care was provided to Patient #37.

Nurse N was interviewed on 3/09/17, beginning at 11:50 AM. She stated no other personal care was documented for Patient #37.

Staff failed to document personal care for Patient #37.

o. Patient #16 was a 71 year old female who was admitted to the hospital on 10/26/16, for treatment of acute lung disease. She was discharged on 10/30/16.

Personal care was not documented for Patient #16 during her stay. Additionally, Patient #16's medical record did not include a discharge summary.

Nurse N was interviewed on 3/09/17, beginning at 11:50 AM. She stated personal care was not documented for Patient #16. She also stated Patient #16's record did not contain a discharge summary.

Staff failed to document personal care and a discharge summary for Patient #16.

Based on staff interview and review of medical records and MS bylaws and rules, it was determined the CAH failed to ensure H&Ps conducted by mid-level providers were countersigned by an MD/DO for 2 of 2 patients (#6 and #13) whose records included H&Ps conducted by mid-level providers whose records were reviewed. This resulted in a lack of clarity as to physician oversight. Findings include:

The "Medical Staff Rules" and the "Bylaws & Rules," dated 10/17/12 were reviewed. They did not address the requirement for an MD or DO to countersign H&Ps conducted by mid-level providers. As a result, H&Ps were not co-signed by an MD or DO. Examples include:

1. Patient #6 was a 62 year old female who was admitted on 1/31/17, with a diagnosis of pain, anemia, and wound care.

Patient #6's medical record included an H&P, dated 1/31/17, and signed by the PA. There was no documented physician countersignature or evidence of assumption of responsibility of the H&P by a CAH physician.

The Nurse Educator was interviewed on 3/08/17, beginning at 1:50 PM, and Patient #6's medical record was reviewed in her presence. She confirmed the documented H&P did not include a CAH physician countersignature or evidence of assumption of responsibility.

The CAH failed to ensure Patient #6's H&P documented physician oversight and responsibility.

2. Patient #13 was a 91 year old male who was admitted on 5/31/16, with a diagnosis of muscle weakness, cellulitis, and recurrent falls.

Patient #13's medical record included an H&P, dated 5/31/16, and signed by the PA. There was no documented physician countersignature or evidence of assumption of responsibility of the H&P by a CAH physician.

The Nurse Educator was interviewed on 3/08/17, beginning at 1:55 PM, and Patient #13's medical record was reviewed in her presence. She confirmed the documented H&P did not include a CAH physician countersignature or evidence of assumption of responsibility.

The CAH failed to ensure Patient #13's H&P documented physician oversight and responsibility.



27086

The HIM Manager was interviewed on 3/07/17, at 8:30 AM. When asked if mid-level practitioners were allowed to do H&Ps and if a physician signature was required on H&Ps done by mid-level practitioners, she stated PAs and NPs were generally privileged to do H&Ps and the CAH did not require a physician's signature on the H&Ps completed by midlevel practitioners.

The Chief of Staff was interviewed on 3/08/17 at 8:18 AM. He stated he or back-up physicians provided most of the inpatient care and that mid-level practitioners covered inpatient one, 3 day weekend [Friday, Saturday, and Sunday] per month. They consulted with him when they had questions. He denied co-signing any H&Ps of patients cared for by mid-level practitioners.

The CAH failed to ensure H&Ps conducted by mid-level providers were countersigned by an MD/DO.

Based on staff interview, CAH policy review, and quality document review, it was determined the CAH failed to ensure a periodic evaluation and quality assurance program had been developed and implemented. This resulted in the inability of the CAH to assess its services, identify areas needing improvement, and take steps to improve and monitor quality. Findings include:

1. Refer to C-331 as it relates to the failure of the CAH to ensure an evaluation of its total program was performed.

2. Refer to C-332 as it relates to the failure of the CAH to ensure an evaluation of its total program, including the utilization of services, was performed.

3. Refer to C-333 as it relates to the failure of the CAH to ensure an evaluation of its total program, including a representative sample of both active and closed clinical records, was performed.

4. Refer to C-334 as it relates to the failure of the CAH to ensure an evaluation of its total program, including the CAH's health care policies, was performed.

5. Refer to C-335 as it relates to the failure of the CAH to ensure an evaluation of its total program that determined whether the utilization of services was appropriate, the established policies were followed, and what changes were needed, was performed.

6. Refer to C-336 as it relates to the failure of the CAH to ensure a quality assurance program was developed and maintained.

7. Refer to C-337 as it relates to the failure of the CAH to ensure its quality assurance program evaluated all patient care services and other services affecting patient health and safety.

8. Refer to C-338 as it relates to the failure of the CAH to ensure medication therapy was evaluated.

The cumulative effect of these negative systemic omissions resulted in the inability of the CAH to evaluate the care and services it provided.

Based on staff interview, CAH policy review, and quality document review, it was determined the CAH failed to ensure an evaluation of its total program was performed. This prevented the CAH from analyzing its program and taking action to improve care. Findings include:

The policy "Performance Improvement Plan," not dated, outlined a general PI plan. The policy did not address an evaluation of the CAH's total program.

The Director of Clinical Services was interviewed on 3/08/17, beginning at 1:15 PM. He stated policies did not require an evaluation of the CAH's total program. The surveyor requested documentation of the CAH's evaluation. The Director of Clinical Services stated an evaluation of the CAH's program had not been performed since at least 1/01/16.

The CAH failed to perform an evaluation of its program.

Based on staff interview and review quality documents, it was determined the CAH failed to ensure an evaluation of its total program, including the utilization of services, was performed. This prevented the CAH from analyzing its utilization of services and taking action to improve care. Findings include:

The Director of Clinical Services was interviewed on 3/08/17, beginning at 1:15 PM. The surveyor requested documentation of the CAH's evaluation of its total program. The Director of Clinical Services stated an evaluation of the CAH's program, including the utilization of services, had not been performed since at least 1/01/16.

The CAH failed to perform an evaluation of its program, including the utilization of services.

Based on staff interview and review of quality documents, it was determined the CAH failed to ensure an evaluation of its total program, including a representative sample of both active and closed clinical records, was performed. This prevented the CAH from analyzing the documented care provided to patients and taking action to improve care. Findings include:

The Director of Clinical Services was interviewed on 3/08/17, beginning at 1:15 PM. The surveyor requested documentation of the CAH's evaluation of its total program. The Director of Clinical Services stated an evaluation of the CAH's program, including a representative sample of both active and closed clinical records, had not been performed since at least 1/01/16.

The CAH failed to perform an evaluation of its program, including a representative sample of both active and closed clinical records.

Based on staff interview and review of quality documents, it was determined the CAH failed to ensure an evaluation of its total program, including the CAH's health care policies, was performed. This prevented the CAH from analyzing its health care policies and taking action to align the care provided by staff with the CAH's policies. Findings include:

The Director of Clinical Services was interviewed on 3/08/17, beginning at 1:15 PM. The surveyor requested documentation of the CAH's evaluation of its total program. The Director of Clinical Services stated an evaluation of the CAH's program, including a review of the CAH's health care policies, had not been performed since at least 1/01/16.

The CAH failed to perform an evaluation of its program, including a review of the CAH's health care policies.

Based on staff interview and review of quality documents, it was determined the CAH failed to ensure an evaluation of its total program that determined whether the utilization of services was appropriate, the established policies were followed, and what changes were needed, was performed. This prevented the CAH from analyzing its program and taking action to improve care. Findings include:

The Director of Clinical Services was interviewed on 3/08/17, beginning at 1:15 PM. The surveyor requested documentation of the CAH's evaluation of its total program. The Director of Clinical Services stated an evaluation of the CAH's program that included a determination of whether the utilization of services was appropriate, the established policies were followed, and what changes were needed, had not been performed since at least 1/01/16.

The CAH failed to perform an evaluation of its program.

Based on staff interview, CAH policy review, and quality document review, it was determined the CAH failed to ensure a quality assurance program was developed and maintained. This prevented the CAH from evaluating services from the various hospital departments and from analyzing adverse patient events. Findings include:

1. The policy "Performance Improvement Plan," not dated, outlined a general PI plan, PI teams, and a PI Committee. A specific plan, including quality indicators and specific PI activities, was not outlined in the plan or in other quality documents.

Four sets of minutes of the PI Committee, dated 12/01/15 to 3/6/17, were provided to surveyors. The Director of Clinical Services, interviewed on 3/08/17, beginning at 1:15 PM, stated 1 other set of minutes from July 2016 were written, but he was not able to find them.

The PI Committee meeting minutes did not mention specific quality indicators. The only minutes that mentioned any numbers were dated 1/17/17. Those minutes stated Emergency Department Transfer Communication numbers were near 100 percent. The meeting minutes did not document value judgments regarding the quality of care provided to patients. Follow through was not documented. For example, the 10/18/16 minutes and the 1/17/17 minutes stated PT, dietary, housekeeping, and Medical Staff still needed to develop "projects." The "Action/Follow up" documented in both minutes was to "follow up..." No specific persons or authority were documented with the responsibility to ensure the recommendations were followed. None of the PI Committee meeting minutes mentioned adverse patient events or incidents. Infection control was not mentioned. Medication therapy was not mentioned.

The CAH did not have a dashboard or other method to document data collection and progress toward goals.

The Director of Clinical Services was interviewed on 3/08/17, beginning at 1:15 PM. He stated a PI program, including documentation of PI activities, data collection, and review of PI activities, was not documented. He stated data was gathered for several quality projects that were required for other entities, such as the Medicare Beneficiary Quality Improvement Project. However, he stated this data was not reviewed or analyzed by the CAH's PI program. He stated there was no documentation any data was reviewed or analyzed by the PI program.

The CAH failed to develop and monitor an effective quality assurance program.

2. The policy "Incident - Accidents to Patients - Reporting and Investigation of Incidents," reviewed 6/22/15, stated incidents would be documented and reviewed by a department manager and the risk manager. The policy did not offer specific guidance to staff regarding the investigation and follow up for less serious incidents.

The policy did address major incidents "involving death or serious physical or psychological injury...including the loss of limb or function." For these events, the policy stated "an analysis defining the problem and listing the ideas that narrow down to a root cause" would be documented. A specific procedure for a root cause analysis was not defined.

The policy stated an analysis of event reports would be presented to the PI Committee. However, none of the PI Committee minutes noted above mentioned event reports.

Ten incident reports were documented from 1/01/16 to 3/06/17. Investigation and analysis was not documented for all ten incidents as follows:

a. One report documented an incident that occurred on 8/21/16. The attached nurses notes stated Patient #38, a 25 year old female, presented to the ED at 10:25 PM. She stated she was 39 weeks pregnant. She stated she was in labor with contractions 10 to 15 minutes apart. She stated she had lost her mucous plug an hour prior to arrival. She stated her water had not broken. The note stated the nurse told Patient #38 that the CAH only offered emergency services and did not offer routine delivery services. The note stated the nurse told Patient #38 a physician could see her but she, the patient, would probably be sent to an acute care hospital approximately 72 miles away to deliver. The note stated Patient #38 decided to leave against medical advice to seek treatment elsewhere. She left the CAH at 10:35 PM.

A "QUALITY MANAGEMENT MEMO," dated 8/21/16, was signed by the Chief Nursing Officer, the Risk Manager, and the Director of Clinical Services. The Chief Nursing Officer wrote the physician on call was not notified of Patient #38's arrival in the ED. An investigation of the events was not documented. All 3 persons above checked "no further action was necessary."

b. A "Medication Error Report Form," dated 11/17/16, documented a patient was administered Norco instead of the ordered Oxycodone IR, 2 separate narcotic medications. A "Medication Error Report Form," dated 2/19/17, documented a patient was administered Norco rather than the ordered Percocet (Oxycodone).

Both incident reports documented the patients did not suffer any adverse consequences. Neither incident report stated the incidents were investigated. The incident report, dated 11/17/16, did not document any corrective action regarding the event. The incident report, dated 2/19/17, stated the event was addressed in a staff meeting. No investigation was documented regarding these 2 similar events.

The Director of Clinical Services was interviewed on 3/08/17, beginning at 1:15 PM. He stated the above incidents did not receive any in depth investigation.

The CAH failed to investigate and analyze adverse patient events.

Based on staff interview and review of quality documents, it was determined the CAH failed to ensure its quality assurance program evaluated all patient care services and other services affecting patient health and safety. This prevented the CAH from analyzing all services it provided to ensure they met patients' needs. Findings include:

Four sets of minutes of the PI Committee, dated 12/01/15 to 3/6/17, were provided to surveyors. The Director of Clinical Services, interviewed on 3/08/17, beginning at 1:15 PM, stated 1 other set of minutes from July 2016 were written but he was not able to find them.

The 10/18/16 minutes and the 1/17/17 minutes stated PT, dietary, housekeeping, and Medical Staff still needed to develop "projects." The "Action/Follow up" documented in both minutes was to "follow up..." No other departments of the CAH, such as laboratory services, radiology services and medical records, etc., were mentioned in PI Committee minutes. No activities with data related to the CAH's internal PI program were documented for any department.

The Director of Clinical Services was interviewed on 3/08/17, beginning at 1:15 PM. He stated there was no documentation that the CAHs PI program evaluated specific services.

The CAH failed to evaluate all services.

Based on staff interview, CAH policy review, and quality document review, it was determined the CAH failed to ensure medication therapy was evaluated. This prevented the CAH from evaluating services from the various hospital departments and from analyzing adverse patient events. Findings include:

The policy "Performance Improvement Plan," not dated, did not include medication therapy in the list of items to be monitored.

Four sets of minutes of the PI Committee, dated 12/01/15 to 3/6/17, were provided to surveyors. The Director of Clinical Services, interviewed on 3/08/17 beginning at 1:15 PM, stated 1 other set of minutes from July 2016 were written but he was not able to find them. None of the minutes mentioned medication therapy.

The Director of Clinical Services was interviewed on 3/08/17, beginning at 1:15 PM. He stated medication therapy was not included in the CAH's PI program.

The CAH failed to evaluate medication therapy.

Based on CAH policy review and staff interview, it was determined the CAH failed to ensure written protocols were developed and implemented to address organ, tissue and eye procurement. This had the potential to result in a lack of identification of suitable organ, tissue, and eye donors. Findings include:

1. Refer to C-345 as it relates to the CAH's failure to incorporate an agreement with an OPO.

2. Refer to C-346 as it relates to the CAH's failure to incorporate an agreement with a tissue and eye bank.

3. Refer to C-347 as it relates to the CAH's failure to ensure potential donor families would be approached by an individual trained in the methodology for approaching potential donor families and requesting organ, tissue or eye donation.

4. Refer to C-348 as it relates to the CAH's failure to ensure a written protocol which outlined encouraging discretion and sensitivity with respect to the circumstances, views, and beliefs of potential donor families.

5. Refer to C-349 as it relates to the CAH's failure to work cooperatively with the designated OPO, tissue bank, and eye bank in educating staff on donation issues and reviewing death records to improve identification of potential donors.

The cumulative effect of these difecient practices created the potential for suitable organ, tissue, and eye donors to not be identified.

Based on CAH policy review and staff interview, it was determined the CAH failed to incorporate an agreement with an OPO. This had the potential to interfere with patient family donor options in regards to organ donation for all CAH patients. Findings include:

A CAH policy "Organ & Tissue Donation," undated, stated "Lost Rivers Medical Center [Lost Rivers Memorial Hospital] has an agreement for organ and tissue referral, requesting, and recovery with IORS."

The Director of Clinical Services was interviewed on 3/08/17, beginning at 10:19 AM. When asked which OPO the CAH had an active agreement with, he stated he did not know. When asked for a copy of the active OPO agreement, the Director of Clinical Services was unable to provide one.

The Director of Clinical Services, Director of Human Resources, and CEO were interviewed together on 3/08/17, beginning at 11:40 AM. When asked for a copy of the active OPO agreement, they were unable to provide one. They stated they would find the agreement and provide a copy as soon as possible. A copy of the OPO agreement was not provided by the close of the survey.

The CAH failed to follow their policy and incorporate an agreement with an OPO.

Based on CAH policy review and staff interview, it was determined the CAH failed to incorporate an agreement with at least one tissue and eye bank. This had the potential to interfere with patient family donor options in regards to tissue and eye donation for all CAH patients. Findings include:

A CAH policy "Organ & Tissue Donation," undated, stated "Lost Rivers Medical Center [Lost Rivers Memorial Hospital] has an agreement for organ and tissue referral, requesting, and recovery with IORS."

The Director of Clinical Services was interviewed on 3/08/17, beginning at 10:19 AM. When asked which tissue and eye bank the CAH had an active agreement with, he stated he did not know. When asked for a copy of the active tissue and eye bank agreement, the Director of Clinical Services was unable to provide one.

The Director of Clinical Services, Director of Human Resources, and CEO were interviewed together on 3/08/17, beginning at 11:40 AM. When asked for a copy of the active tissue and eye bank agreement, they were unable to provide one. They stated they would find the agreement and provide a copy as soon as possible. A copy of the tissue and eye bank agreement was not provided by the close of the survey.

The CAH failed to follow their policy and incorporate an agreement with a tissue and eye bank.

Based on staff interview, it was determined the CAH failed to ensure potential donor families would be approached by an individual trained in the methodology for approaching potential donor families and requesting organ, tissue or eye donation. This had the potential to result in failure of the CAH to inform the family of their donation options. Findings include:

The Director of Clinical Services was interviewed on 3/08/17, beginning at 10:19 AM. When asked how the CAH collaborated with the OPO to ensure the family of each potential donor is informed of their donation options, he stated he did not know. When asked who the CAH's designated requestor for donation opportunities was, he stated he did not know. When asked if any CAH staff had completed a course offered or approved by the OPO in the methodology for approaching potential donor families and requesting organ or tissue donation, he stated he did not know. When asked for a copy of the active OPO agreement, the Director of Clinical Services was unable to provide one.

The CAH failed to ensure potential donor families would be approached by an individual trained in the methodology for approaching potential donor families and requesting organ, tissue or eye donation.

Based on CAH policy review and staff interview, it was determined the CAH failed to ensure a written protocol which outlined encouraging discretion and sensitivity with respect to the circumstances, views, and beliefs of potential donor families. This had the potential to interfere with patient family donor options in regards to organ, tissue, and eye donation for all CAH patients. Findings include:

A CAH policy "Organ & Tissue Donation," undated was reviewed. The policy did not include staff instruction or guidance in regards to encouraging discretion and sensitivity with respect to the circumstances, views, and beliefs of potential donor families.

The Director of Clinical Services was interviewed on 3/08/17, beginning at 10:19 AM. When asked how the CAH ensured all potential donor families were approached and informed of their donation rights, he stated he did not know. When asked if the CAH-designated requestor training program addressed the use of discretion, he stated he did not know. The Director of Clinical Services stated he did not know if the CAH had a designated requestor training program or if such a program was the responsibility of the OPO. When asked for a copy of the active OPO agreement, he was unable to provide one.

The CAH failed to ensure a written protocol which outlined encouraging discretion and sensitivity with respect to the circumstances, views, and beliefs of potential donor families.

Based on CAH policy review and staff interview, it was determined the CAH failed to work cooperatively with the designated OPO, tissue bank, and eye bank in educating staff on donation issues and reviewing death records to improve identification of potential donors. This had the potential to result in failure of the facility employees to identify potential organ, tissue and eye donors, as well as failure to inform potential donor families of their donation options. Findings include:

A CAH policy "Organ & Tissue Donation," undated, was reviewed. The policy did not include the process for staff education in regards to donation issues or outline the death record review process to improve identification of potential donors.

The Nurse Educator was interviewed on 3/08/17, beginning at 10:03 AM. When asked what training CAH staff received in regards to the OPO program and donation issues, she stated she did not know. The Nurse Educator was unable to provide staff education materials regarding the OPO program and donation issues. When asked how often OPO training was conducted, she stated she did not know. When asked what protocols were in place to guide death record reviews and analysis, the Nurse Educator stated she did not know.

The Director of Clinical Services was interviewed on 3/08/17, beginning at 10:19 AM. When asked what training CAH staff received in regards to the OPO program and donation issues, he stated he did not know. The Director of Clinical Services was unable to provide staff education materials regarding the OPO program and donation issues. When asked how often OPO training was conducted, he stated he did not know. When asked what protocols were in place to guide death record reviews and analysis, the Director of Clinical Services stated he did not know.

The CAH failed to work cooperatively with the designated OPO, tissue bank, and eye bank in educating staff on donation issues and reviewing death records to improve identification of potential donors.

Based on CAH inpatient admission packet review, CAH swing bed admission packet review, and staff interview, it was determined the CAH failed to ensure patients received notice of their right to privacy in written communication, including sending and receiving unopened mail and having access to stationary, postage, and writing implements at each patient's expense for 7 of 7 swing bed patients (#6, #7, #8, #9, #17, #18, and #19) whose records were reviewed. This had the potential to interfere with each patient's rights while in swing bed status. Findings include:

A CAH inpatient admission packet was reviewed. The packet did not include documentation of notification of patients rights in regards to privacy in written communication or mail.

A CAH swing bed admission packet was reviewed. The packet did not include documentation of notification of patients rights in regards to privacy in written communication or mail.

The Swing Bed Activities Director was interviewed on 3/08/17, beginning at 2:40 PM, and the 2 admission packets were reviewed in her presence. She confirmed neither admission packet contained documentation of notification of patients rights in regards to privacy in written communication or mail.

The CAH failed to ensure patients received notice of their right to privacy in written communication, including sending and receiving unopened mail and having access to stationary, postage, and writing implements at each patient's expense.

Based on CAH swing bed admission packet review and staff interview, it was determined the CAH failed to ensure patients received notice of their right to share a room with his or her spouse when both reside in the same facility and agree to the arrangement. This had the potential to interfere with patient's rights in regards to cohabitation while in swing bed status. Findings include:

A CAH swing bed admission packet was reviewed. The packet did not include documentation of notification of patients rights in regards to sharing a room with his or her spouse when both reside in the same facility and agree to the arrangement.

The Swing Bed Activities Director was interviewed on 3/08/17, beginning at 2:40 PM, and the swing bed admission packet was reviewed in her presence. She confirmed the packet did not include notice of patients right to share a room with his or her spouse when both reside in the same facility and agree to the arrangement.

The CAH failed to ensure patients received notice of their right to share a room with his or her spouse when both reside in the same facility and agree to the arrangement.

Based on record review, CAH policy review, admission packet review, and staff interview, it was determined the CAH failed to ensure 20 of 20 inpatients (#s 1-19 and #37) were informed of their visitation rights. This had the potential to interfere with the exercise of visitation rights. Findings include:

A policy was requested for visitation rights. A policy, "Visiting Hours," dated 10/17/2012, was provided. It included information on rights and restrictions.

An admission packet was reviewed. There was no information included in the admission packet that addressed visitation rights.

Medical records were reviewed for inpatients #1-19 and #37. There was no documentation to indicate patient visitation rights had been provided.

The CFO was interviewed on 3/06/17, at 3:20 PM. She confirmed visitation rights were not specifically provided to patients.

The facility failed to ensure inpatients were informed of their visitation rights.