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551 HIGHLAND DRIVE

ARCO, ID 83213

PATIENT CARE POLICIES

Tag No.: C0278

37262

Based on staff interview, it was determined the CAH failed to ensure a system to avoid potential transmission of infections and communicable diseases was fully implemented, and failed to ensure systems to identify and investigate infections was clearly defined and implemented. This had the potential to impact all staff and patients in the CAH. Failure to follow policies, nationally recognized guidelines, and standard precautions had the potential to allow for transmission of infections. Findings include:

The CNO and ICO were interviewed together on 4/18/17, beginning at 10:25 AM. When asked for a current infection control plan, they were unable to provide one. The ICO had been formally identified and had been in the role for approximately 2 weeks. The CNO and ICO stated they were still in the process of developing a facility-wide infection control plan. They stated the previous infection control plan was insufficient and missing numerous key elements. The CNO and ICO stated they still need to create a new plan from the ground up. They stated they were not currently tracking CAH infections and communicable diseases, but would be doing so in the near future. The CNO stated the ICO would be going through formal infection control training starting in May, 2017. The CNO and ICO confirmed they needed an updated and formal system in place to collect, analyze, and report infection control data. They confirmed they still needed to involve clinical/housekeeping staff from all areas of the CAH to participate in the infection control plan and infection control committee.

The CAH failed to ensure a system to avoid potential transmission of infections and communicable diseases was fully implemented, and failed to ensure systems to identify and investigate infections was clearly defined and implemented.

No Description Available

Tag No.: C0298

37262

Based on medical record review and staff interview, it was determined the CAH failed to ensure nursing care plans were developed and kept current for 1 of 1 current swing bed patients (Patient #3) whose record was reviewed. This had the potential to interfere with complete and consistent delivery of nursing care. Findings include:

Patient #3 was an 87 year old female admitted to swing bed status on 3/31/17, with a diagnosis of right femur fracture. Other pertinent diagnoses included CHF and dementia. Patient #3 was a current patient at the time of the survey.

Patient #3's medical record included a "Nursing Care Plan," dated 4/02/17, and signed by an RN. The care plan, received from HIM on 4/17/17, had not been updated since 4/02/17. Patient #3's care plan did not include reference to her CHF which placed her at risk as follows:

a. Patient #3's medical record included a laboratory results form which documented a critical BNP value of 1320 pg/ml (normal range 5 - 100 pg/ml) on 4/04/17, at 5:50 PM. The Cleveland Clinic website, accessed on 4/19/17, stated "B-type natiuretic peptide (BNP) is a hormone produced by your heart. It is released in response to changes in pressure inside the heart. These changes can be related to heart failure. In general, the level of BNP goes up when heart failure develops or gets worse, and it goes down when the condition is stable." This change in Patient #3's condition was not updated on her care plan.

b. Patient #3's medical record included a "Nursing Assessment," dated 4/04/17, and signed by an RN. The assessment stated:

- "...edema right leg +2..."

- "...edema left leg +2..."

- "...BLE edema noted at hips and thighs, also 2+ [sic] at L foot..."

- "...LLL crackles/rales; fine crackles noted..."

The Mayo Clinic website, accessed on 4/19/17, stated "When one or both of your heart's lower chambers lose their ability to pump blood effectively - as happens in congestive heart failure - the blood can back up in your legs, ankles and feet, causing edema. Heart failure can also cause swelling in your abdomen. Sometimes it can cause fluid to accumulate in your lungs (pulmonary edema), which can lead to shortness of breath." This change in Patient #3's condition was not updated on her care plan.

c. Patient #3's medical record included a laboratory results form which documented a critical BNP value of 1270 pg/ml (normal range 5 - 100 pg/ml) on 4/12/17, at 8:55 AM. This change in Patient #3's condition was not updated on her care plan.

The CNO was interviewed on 4/18/17, beginning at 11:15 AM, and Patient #3's medical record was reviewed in her presence. She confirmed Patient #3's care plan had not been updated to include her CHF and change in condition.

The CAH failed to ensure care plans were developed and kept current for Patient #3.



00023

No Description Available

Tag No.: C0302

Based on medical record review and staff interview, it was determined the CAH failed to ensure complete and accurately documented medical record entries for 2 of 6 ED patients (#2 and #5) whose records were reviewed. This had the potential to interfere with the coordination and provision of patient care. Findings include:

1. Patient #5 was a 73 year old female seen in the ED on 4/16/17, for a right femur fracture.

a. Patient #5's medical record documented she had a medical history of HTN, tremors, weakness, and dizziness. The record also documented she had brain surgery in 2015 for an aneurysm (a bulging, weak area in the wall of an artery in the brain). Patient #5's medication list included atorvastatin, metoprolol, lisinopril, Bactrim, Bufferin, ranitidine, and oxygen for use at night.

Patient #5 was transferred from the CAH to another acute care facility for a higher level of services. Patient #5's medical record included an "EMTALA Transfer Form/Physician Certification," dated 4/16/17, signed by the FNP-C. The transfer form was not complete and did not include all of Patient #5's medical and surgical history.

- The transfer form documented Patient #5's medications as metoprolol, lisinopril, and hydrocodone. The list did not include her cholesterol medication, aspirin, antibiotic, stomach medication, or oxygen. Additionally, the form did not include documentation Patient #5 had brain surgery or that she had tremors and weakness.

- The transfer form included a section for her current vital signs and physical status. The vital sign section was blank.

- The transfer form documented Patient #5 received 1 dose of Dilaudid 0.5 mg IV. However, the ED record documented Patient #5 received a second dose of Dilaudid 0.5 mg prior to her transfer.

During an interview at 11:30 AM on 4/18/17, the CNO reviewed Patient #5's record and confirmed the transfer documentation was incomplete. She also confirmed some of Patient #5's medications and medical history were not included as part of her H&P. The CNO confirmed the transfer form did not include all the medications she received prior to her transfer.

Patient #5's transfer documentation was incomplete and missing pertinent medical information.

b. Patient #5's ED record documented the provider ordered via telephone "Dilaudid 5 mg once Prior to transport phone order by [provider name] now IV Push." The ED RN documented 5 mg of Dilaudid was given to Patient #5 at 12:25 AM on 4/17/17.

Dilaudid, according to the Drugs.com website accessed on 4/19/17, is a narcotic analgesic used to treat moderate to severe pain by acting on the central nervous system. The website stated the IV dose for Dilaudid is 0.2 mg to 1 mg every 2 to 3 hours.

During an interview at 11:30 AM on 4/18/17, the CNO reviewed Patient #5's record and confirmed the order and administration was documented as 5 mg of Dilaudid. She stated she would look for the medication record in the ED to verify whether the dose ordered and documented as given was actually given. At 12:15 PM on 4/19/17, the CNO presented the medication record for the ED and stated she had reviewed it. She stated Patient #5 was given 0.5 mg of Dilaudid and it was incorrectly documented in her record.

Patient #5's record included incorrect documentation of the medications she was given while treated in the ED.

2. Patient #2 was a 48 year old male seen in ED on 4/14/17, with a diagnosis of accidental poisoning.

Patient #2's medical record included an "Admission Summary Sheet," dated 4/14/17, and signed by an RN. The form included a section titled "Authorization for release of Information," initialed by the Patient #2, but did not document who he was authorizing information to be released to, as it was left blank. Additionally, the form included a section titled "I hereby acknowledge by my initial that I have read or that the foregoing documents have been explained to me," signed by Patient #2. This section also included 3 portions: a date for patient signature, a witness signature, and a date for the witness signature. These 3 portions were blank.

The CNO was interviewed on 4/17/17, beginning at 12:10 PM, and Patient #2's medical record was reviewed in her presence. She confirmed the "Admission Summary Sheet" was not complete.

The CAH failed to ensure complete and accurately documented medical record entries.


00023



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