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Based on medical record review, policy review, personnel file review, Idaho Board of Nursing Rules review, governing body meeting minute review, and staff interview, it was determined the CAH failed to ensure staff roles were defined, directed, and followed state law. This resulted in a lack of leadership and direction to CAH staff. Findings include:

1. Refer to C-962, as it relates to the Governing Body's failure to ensure oversight of the CAH's operation and program, accountability of staff, and safe patient care were maintained.

2. Refer to C-1004, Condition of Participation: Provision of Services, and associated standard level deficiencies, as they relate to the CAH's failure to ensure directed patient care by CAH staff to meet patients' needs was provided in accordance with appropriately written policies and state law.

Based on facility policy, governing body meeting minutes review, Medical Staff Bylaws review, Idaho Board of Nursing review, and staff interview, it was determined the Governing Body failed to maintain oversight of the CAH's operation and staff to ensure accountability of staff and safe patient care. This resulted in incomplete and missing policies, and lack of oversight of staff. Findings include:

1. The Governing Body failed to ensure system-wide policies were created and/or active and executed for patient care delivery. Examples include:

The hospital was notified of an immediate jeopardy at Provision of Services tag 1004 on 12/21/22 at 12:10 PM in relation to the CAH utilizing UAP's in the hospital in a non defined role with no documented oversight.

Idaho Board of Nursing Rules 24.34.01, accessed 12/21/22, stated the following:

"35. Unlicensed Assistive Personnel (UAP). This term is used to designate unlicensed personnel employed to perform nursing care services under the direction and supervision of licensed nurses....UAPs may not be delegated procedures involving acts that require nursing assessment or diagnosis, establishment of a plan of care or teaching, the exercise of nursing judgment, or procedures requiring specialized nursing knowledge, skills or techniques. (3-31-22)"

The rules also defined the UAP, and included their allowable role as:

"The nursing care tasks that may be delegated to UAPs shall be stated in writing in the practice setting. Decisions concerning delegation will be determined in accordance with the provisions of Section 400 of these rules. UAPs may complement the licensed nurse in the performance of nursing functions, but cannot substitute for the licensed nurse; UAPs cannot redelegate a delegated act."

The CAH started utilizing an MA in the hospital approximately 10/2021.

Governing Body Meeting minutes were reviewed from 8/2022 to current. There was no documented discussion of the new MA role. Surveyors requested any documentation that the MA role was discussed at Medical Staff Meetings or Governing body meetings in the last year since the MA was hired to work in the facility, and the new position was created. No documentation was provided.

The HR director was interviewed 12/21/22 beginning at 11:00 AM. Surveyors requested any policies created for the role of the MA in the facility. The HR manager stated, "We don't have any MA specific policies for the hospital."

The CEO/Administrator who was approved by the governing body was interviewed on 12/21/22 beginning at 12:00 PM. When asked the role of the MA, he stated it is a supplement for the nursing staff in assisting them as needed. When asked if the CAH had developed new policies regarding the role of the MA or the MA duties. He stated there were no hospital approved policies governing the MAs. The CEO was asked who approved the MA role, and he stated, "New roles in the hospital don't need approval from Medical Staff ... I approved it." Surveyors requested any documentation that the MA role was discussed at Medical Staff Meetings or Governing body meetings in the last year since the MA was hired to work in the facility, and the new position was created. The CEO confirmed there was no documentation the MA role was discussed or approved.

Facility Medical Staff Bylaws were reviewed. There was no discussion of the role of the MA or the oversight specific to an MA required by the Medical Staff.

The Governing Body of the CAH failed to define the MA role, and create specific policies outlining the MA role.

2. The facility failed to provide oversight to the care being delivered by UAP's

Refer to C-1006 as it relates to the CAH's failure to ensure medications were given by qualified and licensed staff, and the CAH's failure to ensure patient assessments were completed by licensed and competent staff.

A facility policy titled "Medication Administration" dated 3/14/2018 included:

"Administration [of medication] shall be by a physician, registered nurse, licensed practical/vocational nurse, respiratory therapist, physical therapists and or their respective supervised students."

The MA was interviewed 12/21/22 beginning at 10:30 AM. When asked what his role at the hospital is, he stated he does vital signs, assists with nursing cares, and gives IM injections, SubQ [subcutaneous] injections, breathing treatments, and oral medications. When asked if he could take medication orders from the MD, he stated "yes." When asked if he was licensed through the state of Idaho, he stated "no." When asked who he reported to, he stated the DON or licensed nurse on duty. When asked if he has any one-on-one with the MD or midlevel providers in regard to chart reviews or care provided, he stated he does not. When asked if a physician reviews his charts or if he reports to a physician, the MA stated he does not.

When the MA was read the above definition of UAP under the Idaho Board of Nursing rules he agreed that is the duties he performed at the hospital however he stated, "I am not governed by the Board of Nursing." He stated that the role and deffinition of UAP does not apply to him.

When the MA was asked if he could give IV medications he stated "no." When asked if Normal Saline IV was considered an IV medication he stated that it was. When asked if he has given Normal Saline IV he stated "Yes." He was unable to elaborate on why he was able to give Normal Saline IV when he was not allowed to give IV medications. The MA confirmed that he had been starting IV's and infusing Normal Saline. The facility policy was read to the MA. The MA stated, "I wasn't aware MAs can't hang NS per this facility, take that up with [the DON]."

When the MA was asked if he can administer controlled substances, he stated "yes I can" and when asked what route he can administer medications he stated "IM, SubQ[subcutaneous], transdermal as approved by the hospital and doctor." When the MA was read the policy of medication administration, which stated medication administration could only be performed by physician, RN, LPN, RT, PT or supervised students, he stated he was unaware of that policy.

When The MA was asked if he could do patient assessments, he stated "no." When asked if evaluating a patient's pain was an assessment, the MA stated it was, and when asked if he had done pain assessments he stated "yes."

The MA was asked how his role was different than a Licensed Nurse. He stated an LPN could perform patient assessments. When asked if there were any other differences he stated he did not believe so. When asked about the training he received as a MA, he stated he went to an online program based out of Michigan and received a certificate online. When asked if he had any hands-on clinical experience, he stated his experience was through a family medicine clinic in eastern Idaho.

The CMO was interviewed 12/22/22 beginning at 8:15 AM. When asked if he does any chart reviews specific to the UAP/MA role he stated he would review 10 percent of charts of the mid level providers but nothing specific to the care being provided by the MA. When asked the MA role at the CAH, the CMO stated it was his understanding the UAP/MA could give PRN oral medications and assist with the nurse. The CMO stated the MA could not give IV and IM medications. The CMO stated he was unaware the MA/UAP was giving medications other than oral medications.

The facility failed to provide oversight for all patient care being delivered by UAP's in the CAH.

Based on observation, medical record review, policy review, Idaho Board of Nursing Rules review, facility document review, and staff interview, it was determined the CAH failed to ensure directed patient care by CAH staff to meet patients' needs was provided in accordance with appropriately written policies and state law. This resulted in UAP's providing care and treatments not in accordance with state law and had the potential for poor patient outcomes for all patients receiving care at the CAH. Findings include:

1. Refer to C-1006, as it relates to the CAH's failure to ensure healthcare services were provided in accordance with appropriately written policies and state law.

2. Refer to C-1016, as it relates to the CAH's failure to ensure controlled substances were effectively and appropriately monitored.

3. Refer to C-1049, as it relates to the CAH's failure to ensure all medications were administered to patients by an RN or under the supervision of an RN.

The CAH was notified of an immediate jeopardy at Provision of Services tag 1004 on 12/21/22 at 12:10 PM. A plan of correction was submitted and accepted on 12/21/22 at 2:06 PM. The plan stated: "In order to bring [CAH] out of Immediate Jeopardy, as of 12:45 PM we have placed all UAPs on administrative leave and suspended their employment services in the acute hospital setting...[CAH] will not employ UAPs in the acute setting unless or until all policies are clear as to the functions that can be done by UAPs, in accordance with applicable Federal and Idaho laws."

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


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Based on record review, staff interview, CAH policy review, Idaho Board of Nursing Rules review, personnel file review, and observation, it was determined the CAH failed to ensure medications were administered and patient assessments were performed in accordance with state law and CAH policy. Additionally, the CAH failed to ensure staff were trained and oriented to the CAH's ED. This directly affected 12 of 15 patients (Patients#1, #2, #3, #4 #5, #6, #7, #8, #9, #10, #11, and #14) whose records were reviewed. This put all patients receiving care at the CAH at risk of negative outcomes. Findings include:

Idaho Board of Nursing Rules 24.34.01, accessed 12/21/22, stated the following:

"Administration of Medications. The process whereby a prescribed medication is given to a patient by one (1) of several routes. Administration of medication is a complex nursing responsibility which requires a knowledge of anatomy, physiology, pathophysiology, and pharmacology. Only persons authorized under Board statutes and these rules may administer medications and treatments as prescribed by health care providers authorized to prescribe medications."

The rules also defined the UAP, and included their allowable role as:

"The nursing care tasks that may be delegated to UAPs shall be stated in writing in the practice setting. Decisions concerning delegation will be determined in accordance with the provisions of Section 400 of these rules. UAPs may complement the licensed nurse in the performance of nursing functions, but cannot substitute for the licensed nurse; UAPs cannot redelegate a delegated act."

The rules also included the definition of the UAP as follows:

"35. Unlicensed Assistive Personnel (UAP). This term is used to designate unlicensed personnel employed to perform nursing care services under the direction and supervision of licensed nurses. The term also includes licensed or credentialed health care workers whose job responsibilities extend to health care services beyond their usual and customary roles and which activities are provided under the direction and supervision of licensed nurses. UAPs are prohibited from performing any licensed nurse functions that are specifically defined in Section 54- 1402, Idaho Code. UAPs may not be delegated procedures involving acts that require nursing assessment or diagnosis, establishment of a plan of care or teaching, the exercise of nursing judgment, or procedures requiring specialized nursing knowledge, skills or techniques. (3-31-22)"

Additionally the UAP's role included:

"UAPs may complement the licensed nurse in the performance of nursing functions, but cannot substitute for the licensed nurse." The rules also stated, "UAPs in care settings may assist patients who cannot independently self-administer medications ... Assistance with medication may include: breaking a scored tablet, crushing a tablet, instilling eye, ear or nose drops, giving medication through a pre-mixed nebulizer inhaler or gastric (non-nasogastric) tube, assisting with oral or topical medications and insertion of suppositories." The rules did not speak to delegation of IV line insertion and IV therapy to UAP.

According to RXlist.com, accessed 12/21/22, "Normal Saline is a prescription medicine used for fluid and electrolyte replenishment for intravenous administration." (https://www.rxlist.com/normal-saline-drug.htm)

A CAH policy titled "Medication Administration" dated 3/14/2018 included:

"Administration [of medication] shall be by a physician, registered nurse, licensed practical/vocational nurse, respiratory therapist, physical therapists and or their respective supervised students." This policy was not followed. Examples include:

1. The CAH failed to ensure medications were given by qualified and licensed staff. Examples include:

a. Patient #1 was a 91 year old female who was admitted to the medical surgical unit on 10/26/22, with a chief complaint of black tarry stool.

Patient #1's medical record included documentation she was given a ceftriaxone IM antibiotic injection. The injection was administered by a MA.

Patient #1's medical record included on 10/27/22 at 8:09 AM Patient #1 had an IV started in her right hand. The record included that Patient #1 was started on Normal Saline IV at a rate of 250 ml/hr. The IV start and Normal Saline administration was documented as given by an MA.

The DON was interviewed on 12/21/22 beginning at 3:00 PM and Patient #1's medical record was reviewed in her presence. She confirmed the MA gave the IM injection and the MA was not allowed to give the injection per CAH policy. The DON stated the MA could not administer Normal Saline or give any medications IV.

b. Patient #2 was a 32 year old female who was seen in the ED on 10/26/22, with a chief complaint of arm pain.

Patient #2's medical record included documentation she was given a Toradol 60mg IM injection. The IM injection was administered by the MA.

The DON was interviewed on 12/21/22 beginning at 3:00 PM and Patient #2's medical record was reviewed in her presence. The DON confirmed the MA gave the IM injection and the MA was not allowed to give the injection per CAH policy.

c. Patient #3 was a 37 year old male seen in the ED on 10/01/22 with a chief complaint of a left hand injury.

Patient #3's medical record included documentation he was given Morphine 4mg IM injection by the MA.

The DON was interviewed on 12/21/22 beginning at 3:00 PM and Patient #3's medical record was reviewed in her presence. The DON confirmed the MA gave the IM injection and the MA was not allowed to give the injection per CAH policy.

d. Patient #4 was a 74 year old female seen in the ED on 10/04/22 with a chief complaint of a finger injury.

Patient #4's medical record included documentation she was given a Toradol 60mg IM injection by an MA.

The DON was interviewed on 12/21/22 beginning at 3:00 PM and Patient #4's medical record was reviewed in her presence. The DON confirmed the MA gave the IM injection and the MA was not allowed to give the injection per CAH policy.

e. Patient #5 was a 27 year old male who presented to the ED on 10/01/22 with a chief complaint of head, neck, and back pain.

Patient #5's ED record included documentation Patient #5 was administered a Toradol 60mg IM injection by a MA.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM, and the record of Patient #5 was reviewed in her presence. The DON confirmed the MA administered the toradol injection. The DON agreed that administration of IM medications by a MA was not according to CAH policy.

f. Patient #6 was a 73 year old male who presented to the ED on 12/28/22 with a chief complaint of shortness of breath and cough. Patient #6 was subsequently admitted to the Observation Unit.

Patient #6's medical record included documentation that, on 12/30/22, Patient #6 was administered heparin 5000unit/ml subcutaneously by the MA.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM, and the record of Patient #6 was reviewed in her presence. The DON confirmed the MA administered the heparin injection. The DON agreed that the administration of heparin by a MA was not according to CAH policy.

g. Patient #7 was a 60 year old female who presented to the ED on 11/18/22 with a chief complaint of chest pain and shoulder pain.

Patient #7's medical record included documentation that, on 11/18/22, Patient #7 was administered 60mg Toradol IM injection by the MA.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM and the medical record of Patient #7 was reviewed in her presence. The DON confirmed the MA administered the Toradol injection. The DON agreed that the administration of Toradol IM by a MA was not according to CAH policy.

h. Patient #8 was a 76 year old female admitted to the Medical Surgical unit on 11/05/22 with a diagnosis of Covid-19 and hypoxia.

Patient #8 was given the following medications subcutaneously by the MA:

- Lovenox 40mg/0.4ml on 11/05/22 at 20:09
- Insulin Lispro 100 units/ml on 11/05/22 at 21:42
- Insulin Levemir 100 unit/ml on 11/06/22 at 20:00
- Insulin Lispro 100 units/ml on 11/06/22 PRN at 21:52.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM and medical record of Patient #8 was reviewed in her presence. The DON confirmed the MA administered the subcutaneous Lovenox and insulin. The DON agreed that the administration of IM injections by a MA was not according to CAH policy.

i. Patient #9 was a 70 year old female admitted to the Medical Surgical unit on 11/30/22 with a diagnosis of hypoxic respiratory failure.

Patient #9's medical record included documentation that Patient #9 on 12/1/22 at 6:52 AM, Patient #9 was assessed by the MA with "moderate pain" and administered Prn Acetaminophen ER 650 MG oral. On 12/1/22, Patient #9 was administered heparin 5000 unit/ml subcutaneously by the MA.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM and the medical record of Patient #9 was reviewed. The DON confirmed that the MA administered PRN acetaminophen and heparin. The DON agreed the MA did not act according to CAH policy.

j. Patient #10 was a 54 year old male admitted to the Medical Surgical unit on 11/29/22 with a diagnosis of Covid pneumonia.

Patient #10's medical record included documentation that Patient #10, on 11/29/22, was administered heparin 5000 units/ml subcutaneously by the MA.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM and the medical record of Patient #10 was reviewed in her presence. The DON confirmed that the MA administered heparin. The DON agreed the MA did not act according to CAH policy.

k. Patient #11 was a 72 year old female admitted to a Swing Bed [inpatient] on 10/13/22 with an unknown diagnosis.

Patient #11's medical record included documentation that Patient #11, on 10/23/22 at 3:49 AM, was administered heparin 5000 units/ml subcutaneously by the MA.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM and the medical record of Patient #11 was reviewed in her presence. The DON confirmed that the MA administered heparin. The DON agreed the MA did not act according to CAH policy.

2. The CAH failed to ensure patient assessments were completed by licensed and competent staff. Examples include:

a. Patient #2 was a 42 year old female who was seen in the ED on 10/26/22, with a chief complaint of arm pain.

Patient #2's medical record included that her pain was assessed by the MA prior to giving pain medication. The MA documented the pain assessment as an 8 on a scale of 1 to 10 with 10 being the worst pain.

The DON was interviewed on 12/21/22 beginning at 3:00 PM and Patient #2's medical record was reviewed in her presence. She confirmed the MA performed the pain assessment and stated the MA is not allowed to do patient assessments including pain assessments.

b. Patient #3 was 37 year old male seen in the ED on 10/01/22 with a chief complaint of a left hand injury.

Patient #3's medical record included that his pain was assessed by the MA prior to giving a pain medication. The MA documented the pain assessment as an 8 on a scale of 1 to 10 with 10 being the worst pain. Additionally, Patient #3's response to the pain medication was assessed by the MA. The MA documented Patient #3's pain had improved from an 8 to a 3 on a scale of 1 to 10.

The DON was interviewed on 12/21/22 beginning at 3:00 PM and Patient #3's medical record was reviewed in her presence. She confirmed the MA performed the pain assessment and stated the MA is not allowed to do patient assessments including pain assessments.



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c. Patient #7 was a 60 year old female who presented to the ED on 11/18/22 with a chief complaint of chest pain and shoulder pain.

Patient #7's ED record contained documentation from the MA which stated Patient #7 had a pain level of 8 on a pain scale of 1 to 10 with 10 being the worst pain.

The DON was interviewed on 12/21/22 beginning at 3:00 PM and the medical record of Patient #7 was reviewed in her presence. The DON confirmed the MA documented a pain assessment. The DON agreed that an MA is not allowed to perform patient assessments including pain assessments.

d. Patient #9 was a 70 year old female admitted to the Medical Surgical unit on 11/30/22 with a diagnosis of hypoxic respiratory failure.

On 12/1/22 at 6:52 AM, Patient #9 was assessed by the MA with "moderate pain" and administered acetaminophen ER 650 MG tablet oral.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM and medical record of Patient #9 was reviewed in her presence. The DON confirmed that the MA conducted the pain assessment. The DON agreed that a MA is not allowed to perform patient assessments including pain assessments.

e. Patient #14 was an 81 year old male admitted to the Medical Surgical unit on 10/02/22 with a diagnosis of end of life care, comfort measures.

On 10/17/22 at 3:53 AM, a CNA (certified nurse assistant/UAP) documented pain assessment as "pain improved" after a morphine injection by RN.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM and medical record of Patient #14 was reviewed in her presence. The DON confirmed that the CNA conducted a pain assessment. The DON agreed that a CNA/UAP is not allowed to perform patient assessments including pain assessments.

The CAH was notified of an Immediate Jeopardy at Provision of Services tag 1004 on 12/21/22 at 12:10 PM. A plan of correction was submitted and accepted on 12/21/22 at 2:06 PM. The plan stated: "In order to bring [CAH] out of Immediate Jeopardy, as of 12:45 PM we have placed all UAPs on administrative leave and suspended their employment services in the acute hospital setting...[CAH] will not employ UAPs in the acute setting unless or until all policies are clear as to the functions that can be done by UAPs, in accordance with applicable Federal and Idaho laws...."

On-site verification of the abatement plan of removal of all UAPs was conducted at 2:15 PM. The Immediate Jeopardy was removed at 2:20 PM.


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3. The CAH failed to follow policy in maintaining ED competencies and orientation to the ED.

A CAH policy titled, "Orientation" dated, 1/22/2018, stated:

"A structured orientation program is designed for each new employee based on their job description. It is the Department Manager's responsibility to provide the new employee with this orientation."

A CAH policy titled, "Staff Competency- Credentials & CE" dated, 9/25/2017, stated:

"POLICY: To maintain ongoing competency of staff in specialty departments and patient care areas, the Power County Hospital District Human Resource Department (HR) will track staff credentials and continuing education credits. PROCEDURE: The HR staff will maintain the following information on the staff members of the Acute/Outpatient/Emergency Department:

- Ongoing in-service attendance

- Current orientation or reorientation

- Annual hospital wide healthcare education (SWANK); and

- Ongoing evaluation of competency within the Inpatient, Outpatient/Emergency Department." This policy was not followed. Examples include:

Four personnel files were reviewed for two RN's, an LPN, and an MA who worked in the ED. There were no documented competencies and orientation to the ED.

On 12/21/22 beginning at 3:00 PM, the DON and Administrator were interviewed about the process of orientation for staff at the CAH. The DON stated that she did not have an orientation checklist for the RNs, LPNs, CNAs or MA. When asked how she knows staff is competent and able to be off orientation, the DON stated, "If staff feels comfortable and I feel comfortable then they are off orientation."

On 12/22/22 beginning at 09:29 AM, the DON and an LPN were interviewed about ED specific trainings and competencies. The DON and LPN confirmed that no specific ED competencies were documented.

The CAH failed to ensure ED specific competencies and orientation were documented.

Based on observation, staff interviews, and policy review, it was determined the CAH failed to ensure controlled substances were accurately monitored per policy. This had the potential to allow controlled substances to be unaccounted for. Findings include:

The CAH failed to ensure controlled substances were accurately monitored by licensed CAH staff .

A CAH policy titled, "Schedule Controlled Medications" dated 2/01/2013, stated:

"4.1 The licensed nurse administering the medication on the narcotic record at the time of the patient administration must document each individual dose of scheduled medication. Documentation includes date, patient name, medication, dosage administered, ordering provider, and nurse signature. All wasted medication must be accounted for and documented in the same manner with two licensed nurses wasting the medication..."

"1.3 The RN Supervisor is responsible for the medication cart and double-lock box and its subsequent keys..."

Additionally the policy included, "The RN Supervisor is responsible for an accurate count of scheduled medications by doing and [sic] inventory count of the floor stock at shift changes with the oncoming RN Supervisor." This policy was not followed. Examples include:

An observation was conducted with the LPN, DON, and MA on 12/21/22 beginning at 9:30 AM. The LPN was asked to demonstrate how a narcotic count is performed at the beginning of each shift. The LPN and a MA got the narcotic keys from the DON. The LPN was observed using her badge to gain access to the medication room. The LPN unlocked a narcotic cabinet with the key obtained from the DON. There were 4 binders with pouches containing controlled substances in the locked cabinet. The LPN and MA began counting the medications together.

The narcotic count book was reviewed and it was noted that the narcotic count that was to be done at the end of the days shift was already completed and signed. The LPN was interviewed at the time of the observation about why she had signed off on the narcotic count 8 hours prior to the end of shift. The LPN stated, "it's a bad habit." When asked if an LPN and MA can perform the narcotic count the LPN stated "yes."

The surveyor reviewed the "Power County Hospital NARCOTIC COUNT" for December 2022. The narcotic count form was signed by an MA 8 of the times and signed 66 times by LPNs. There were 9 missing signatures on the narcotic count sheet. There were no RN signatures on the narcotic form for the month of December. Additionally, on the narcotic sheet labeled Lorazepam injection, the MA signed on 11/10 that he gave 0.5 and wasted 0.5. The witness signatures were by the MA and an RN.

The MA was interviewed 12/21/22 beginning at 9:30 AM. When asked why his signature was the only one for 4 of the shifts in December, the MA stated that he signs the sheet because he "forgets and gets busy."

On 12/21/22 beginning at 12:30 PM, the DON was interviewed. The DON confirmed that RNs should be performing narcotic counts per policy. The DON reviewed the narcotic count sheet for December and confirmed that multiple shifts had only the MA signing the sheet.

The CAH pharmacist was interviewed 12/21/22 beginning at 9:00 AM. When asked who has access to the controlled substances stored at the nursing station, the pharmacist stated the RN has the key and is the one who should be accessing it. When the pharmacist was asked who should perform the controlled substance counts at the end of shifts, he said it should be the RN performing the counts. When the pharmacist was asked who can draw up and administer controlled substances, he stated "I think only the RN." When the pharmacist was asked if an MA can administer controlled substances, he stated "not to my knowledge." When the pharmacist was asked who can witness high risk medication draws and witness controlled substance waste, he stated only the RN and LPN.

The CAH failed to ensure that controlled substances were accurately monitored, administered and waste witnessed per CAH policy.


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Based on policy review, record review, and staff interview, it was determined the CAH failed to ensure directed patient care by LPNs was provided in accordance with written policies and state law. LPNs documented administering IV antibiotics to 2 of 15 patients (Patient #6 and Patient #10) whose records were reviewed. This had the potential for poor patient outcomes for all patients receiving care at the CAH. Examples include:

A CAH policy titled: Medication Administration, effective: 3/14/18 was reviewed. The policy read: "Medications shall be administered only upon the order of physicians ... Licensed practical/vocational nurses may administer IV electrolytes, nutrients, blood and blood products, if IV certified, and all IM, subcutaneous, intradermal, rectal, topical, sublingual and oral medications, if not specially[sic] excluded elsewhere by medical staff by-laws."

a. Patient #6 was a 73 year old male who presented to the ED on 12/28/22 with a chief complaint of shortness of breath and cough. Patient #6 was subsequently admitted to Observation.

On 12/28/22, patient #6 was administered an IV dose of Levoflaxacin 750 mg in 150ml D5W. The antibiotic was administered by an LPN. IV antibiotic administration is not allowed by an LPN.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM and record of Patient #6 was reviewed. The DON confirmed the antibiotic was administered by an LPN. The DON agreed that the LPN may not administer IV medications.

b. Patient #10 was a 54 year old male admitted to the Medical Surgical unit on 11/29/22 with a diagnosis of Covid pneumonia.

On 11/29/22, Patient #10 was administered an IV dose of Azithromycin 500 mg in 250 ML Normal Saline. The antibiotic was administered by an LPN. IV antibiotic administration is not allowed by an LPN.

An interview was conducted with the DON on 12/21/22 beginning at 3:00 PM and medical record of Patient #10 was reviewed. The DON confirmed the IV antibiotic was administered by the LPN. The DON agreed that the LPN may not administer IV antibiotic medications.

The CAH failed to ensure LPNs followed all CAH policies related to medication administration.