The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

KOOTENAI HEALTH 2003 KOOTENAI HEALTH WAY COEUR D'ALENE, ID 83814 Oct. 29, 2015
VIOLATION: ORGANIZATION OF EMERGENCY SERVICES Tag No: A1102
Based on staff interview and document review, it was determined the hospital failed to ensure the emergency services was organized under the direction of a single qualified member of the medical staff. This resulted in a lack of clear medical staff leadership in the ED. Findings include:

The list of the hospital's medical directors was reviewed. There was no reference to a medical director for the ED. This was confirmed by the Regulatory Compliance Officer during interview on 10/27/15 at 12:00 PM.

The RN Director of the ED was interviewed on 10/27/15 at 1:15 PM. She referenced the name of a contracted ED physician who served in the role of Medical Director for the ED. Evidence of appointment as medical director was requested from the medical staff office. None was provided.

The Chief of Staff and the physician identified by the RN Director of the ED as the medical director for the ED were interviewed together on 10/28/15 at 3:45 PM. They both confirmed there was not a single member of the medical staff appointed to direct the ED services. The Chief of Staff explained the hospital's model was to provide three contracted ED physicians to serve in leadership. He stated they would make corrections to appoint a single medical director to the ED.

ED services were not organized under the direction of one qualified member of the medical staff.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policies, patient records, and staff interviews, it was determined the facility failed to ensure informed consent was properly obtained for 1 of 1 patient (#3) whose consents were reviewed. This had the potential to result in procedures being performed on individuals who were not able to fully understand the risks and complications associated with the proposed procedure. Findings include:

A policy titled "Informed Consent," dated 9/15/14, stated "A patient should not sign the authorization form if under the influence of drugs or alcohol. If this situation occurs, the physician (or other provider of service) may make an assessment of the patient's mental capacity for understanding, document the capacity in the progress notes, and have the patient sign, date and time the Informed Consent."

Patient #3 was a [AGE] year old male who was admitted on [DATE] for care related to an abdominal abscess and ruptured diverticulitis. He had a history of drug abuse and recent methamphetamine use.

Patient #3's record included educational needs on his admission assessment. The assessment also listed barriers to learning, which included communication, cultural, pain, and substance use.

Patient #3's record documented he was scheduled for a procedure in the radiology department on 12/01/14. A consent was signed by Patient #3 for the placement of a catheter to drain his abdominal abscess. The consent form stated moderate sedation would be used. The consent was signed by Patient #3 on 12/01/14 at 7:35 AM. His signature consisted of initials beside an "X" mark.

Patient #3's record noted that upon his arrival for the procedure, his blood pressure was low, and he was drowsy. Patient #3's blood pressure was 149/73 when he was admitted on [DATE] at 8:47 PM. His blood pressure at 5:40 AM on 12/01/15 was 115/68. When he arrived in the procedure room at 7:55 AM, his blood pressure was 99/45.

The RN documented Patient #3 was drowsy and taking his own pain medications. She stated in her note "Pt came to CT for a procedure. Pt was able to answer questions. Pt drowsy would fall asleep after answering questions. MD came and spoke with pt, all questions and concerns answered. MD and myself asked pt if he has been given any pain medications. He said no. When we asked him if he is taking his own medications he stated yes. When asked what they are he was unable to tell us. Due to his vs [vital signs], drowsiness, history of recent meth use, and inability to tell us what medications he is taking we were unable to sedate him for the procedure for his own safety."

The radiologist wrote "The patient was somnolent. Oriented to person, place and time. Understood the procedure, asked an appropriate question and answered direct questions. Medication record was reviewed. No significant pain medications currently per hospital records. Patient was mildly 'giddy'. Nursing [and I] suspected self medication and asked, 'have you been taking her [sic] home medications while in the hospital?' He said 'yes I am.' I suspect opioids. I explained limitedly that we would use lidocaine only."

The physician did not include in his documentation that he determined the procedure was necessary despite the knowledge Patient #3 was under the influence of an undetermined substance. Additionally, his record was clear in noting he had history of drug abuse and had used methamphetamine two days before his admission.

There was no documentation that indicated staff made efforts to determine what legal or illegal substances Patient #3 had taken that may have impacted his condition or caused him to be drowsy or lower his blood pressure. There was no documentation a drug screen had been completed prior to the procedure.

The RN who provided care for Patient #3 during his procedure on 12/01/14, was interviewed by phone on 10/29/15 beginning at 11:40 AM. She stated Patient #3 claimed his girlfriend brought in his medications. She stated the radiologist asked Patient #3 if he wanted to reschedule the procedure, but Patient #3 stated he wanted it done then. The RN stated Patient #3 was not acting "right," he was vague in his responses, and had admitted to recent methamphetamine use. The RN stated the procedure was completed, and when she gave report to Patient #3's RN on the nursing unit, she told the RN that she would need to follow up and make sure illegal substances were not brought in to the hospital.

During an interview on 10/28/15 beginning at 10:15 AM, the Patient Advocate reviewed Patient #3's record and confirmed his record did not include documentation if the procedural consent was obtained before or after it was determined he was under the influence.

The facility failed to ensure informed consent was properly obtained prior to performing Patient #3's invasive procedure.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on staff interview and review of grievance documentation and hospital policy, it was determined the governing body failed to ensure a grievance process was implemented, monitored and responsibility was delegated, in writing, to a grievance committee. This resulted in an incomplete grievance process and the potential for performance improvement opportunities to be missed. Findings include:

1. The hospital's "Patient Grievance Policy," dated 10/01/15, was reviewed. The policy included, but was not limited to, the following information:

"The KH Board of Trustees delegates the responsibility for review and resolution of grievances to the hospital Administration (Chief Executive Officer and Vice Presidents). Administration will designate the appropriate person or persons to investigate the concern, determine what action is needed, and to respond to the patient."

The hospital did not have a grievance committee. This was confirmed by the Patient Advocacy Manager during interview on 10/27/15 at 8:30 AM. He stated that although the hospital did not have a formal committee, they had a department that dealt with grievances.

2. Refer to A-0122 as it relates to the failure of the governing body to ensure grievances were fully investigated and resolved within a time frame specified in hospital policy.

The governing body failed to ensure a grievance process was implemented, monitored and responsibility was delegated, in writing, to a grievance committee.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of hospital policy and grievance documentation, it was determined the hospital failed to ensure complaints were fully investigated and resolved within a time frame specified in policy for 4 of 6 patients (#1, #3, #4, and #10) whose grievance documentation was reviewed. A failure to fully investigate grievances had the potential to interfere with opportunities to implement corrective measures to prevent similar occurrences. Findings include:

The hospital's "Patient Grievance Policy," dated 10/01/15, was reviewed. The policy included, but was not limited to, the following information:

"KH desires to resolve complaints and grievances promptly. Patient Advocacy in coordination with unit leadership, investigates, and responds in a timely fashion. The goal is to respond in writing within seven (7) days from the date a complaint is recorded. Occasionally a grievance may require an extensive investigation. If the grievance will not be resolved within seven days, the hospital will provide a written response with an expected final resolution date."

The grievance policy was not followed. Examples include:

1. Patient #1 was an [AGE] year old female who was seen in the ED on 8/13/15 and subsequently admitted to an inpatient unit. A complaint, that included multiple allegations regarding quality of care, was received by hospital staff on 10/14/15, on behalf of Patient #1, from a family member.

The concerns were referred by patient advocacy to multiple departments (i.e., Admitting, an inpatient unit, and Medical Staff Services) for review, investigation, and response. There was no documentation to indicate the allegations of a 2 hour delay in responding to a request for assistance to the restroom or missed medications had been investigated.

This was confirmed by the Patient Advocacy Manager during interview on 10/27/15 at 8:30 AM. He stated the Patient Advocate who wrote the letter of response on behalf of Patient #1 may know more about the investigation but was not available for interview.

There was lack of documented evidence the grievance filed on behalf of Patient #1 had been fully investigated and resolved.

2. Patient #3 was a [AGE] year old male who was admitted on [DATE]. A verbal complaint was received on 12/02/14 by Patient #3's spouse, on behalf of Patient #3, regarding quality of care and patient rights issues. The concerns were referred by patient advocacy to multiple managers in nursing, social services, and radiology for review, and investigation, and response. The grievance documentation did not include evidence all allegations had been investigated. Specifically, there was no documentation allegations had been investigated related to being held down by multiple staff during a procedure and not given sedation or anesthetic medication.

A letter of response was dated 1/08/15, more than 30 days after receipt of the complaint. There was no letter notifying the complainant of an expected delay beyond the 7 day time frame specified in policy.

The Patient Advocacy Manager was interviewed on 10/27/15 at 8:30 AM. He confirmed missing documentation regarding the specific allegations. He also confirmed a letter indicating delay in completing the investigation was not sent.

3. Patient #4 was an [AGE] year old female who was admitted as an inpatient on 2/16/15. A complaint was received on 2/20/15, from a family member, regarding a lack of hygiene care during Patient #4's hospitalization .

A letter of response was dated 4/02/15, more than 30 days from the time the complaint was filed. There was no letter notifying the complainant of an expected delay beyond the 7 day time frame specified in policy. This was confirmed by the Patient Advocacy Manager during an interview on 10/27/15 at 8:30 AM.

4. Patient #10 was a [AGE] year old female who was seen in the ED on 7/28/15. She complained to staff on the day of the ED visit that a staff member was rude to her.

The grievance file included documentation the complaint had been referred to managers for investigation of the complaint. There was no documentation the allegations had been investigated with subsequent findings.

During interview on 10/27/15 at 8:30 AM, the Patient Advocacy Manager stated there was documentation of a plan to talk to two individuals. However, additional information was not present.

There was lack of documented evidence Patient #10's grievance had been investigated and resolved.

The facility failed to ensure all grievances were fully investigated and resolved within specified time frames.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure patient records comprehensively documented all interventions taken to ensure care was provided in a safe setting for 4 of 21 patients (#2, #7, #8, and #9) whose records were reviewed. This had the potential to interfere with patient safety and missed opportunities for the hospital to evaluate its care and services. Findings include:

1. A hospital policy, "Management of the Patient Requiring Psychiatric Evaluation," dated 10/07/14, was reviewed. The policy included, but was not limited to, the following information:

- "Patients verbalizing or demonstrating suicidal ideation (SI) must be under continuous observation. Voluntary patients demonstrating SI must be observed by a CNA or personal safety aide (PSA), under the direct supervision of the primary RN, at all times. Involuntary patients, such as those on a Protective Custody Hold, must be observed by a police officer or a member of Kootenai Health (KH) security."

- "Patients demonstrating SI or homicidal ideation (HI) will: a. Change into hospital gown, removing all clothing. b. Have clothing and belongings labeled and secured. c. Be searched by RN/Security... Have the exam room made into a safe room."

Patient records did not include documentation that all suicide precautions had been implemented in the ED, as follows:

a. Patient #7 was a [AGE] year old male who was brought to the ED on a police hold on 5/26/15 at 11:10 PM related to alcohol intoxication and suicidal ideation. Documentation indicated security monitored Patient #7 continuously from 5/26/15 at 11:40 PM until 5/27/15 at 11:00 AM. Continuous monitoring was discontinued after Patient #7 had been evaluated by a case manager, a designated examiner, and after Patient #7 had signed a safety contract. However, there was no documentation Patient #7 had been changed into a hospital gown, searched by RN/Security, or that the exam room was made safe in accordance with hospital policy.

b. Patient #9 was a [AGE] year old female who was brought to the ED by a friend on 8/11/15 at 9:18 AM. She presented with multiple complaints, such as vomiting, constipation, and generalized body aches. A suicide assessment, dated 8/11/15 at 12:23 PM, indicated Patient #9 expressed SI and intent to commit suicide. A psychiatrist was consulted and a behavioral health evaluation was conducted. It was determined Patient #9 did not meet criteria for inpatient admission and she was subsequently discharged on [DATE] at 3:56 PM with a referral to a behavioral health specialist.

Patient #9's medical record did not include documentation of continuous monitoring in the ED. It also did not include documentation Patient #9 was changed into a gown, searched by RN/Security, or that the exam room was made safe in accordance with hospital policy.

c. Patient #8 was a [AGE] year old female who was brought to the ED by two friends on 7/07/15 at 12:25 AM for SI. A psychiatric assessment and social services consulted were provided. Documentation was presented that Patient #8 had been continuously monitored from 7/07/15 at 1:30 AM until she was discharged to the care of a friend at 8:59 AM with instructions to follow-up with behavioral health.

However, Patient #8's medical record did not include documentation she was changed into a gown during her ED stay, searched by RN/Security, or that the exam room was made safe in accordance with hospital policy.

The RN Director of the ED and a staff RN were interviewed on 10/27/15 beginning at 10:30 AM. The ED Staff RN stated precautions were always taken, but confirmed documentation was missing in Patient #7 - #9's medical records. The ED Director stated they had a policy to take actions but did not have a policy to document them.

The facility failed to ensure patient records documented all suicide precautions which were implemented to ensure patients received care in a safe setting.





2. A policy titled "Handling of Medications Brought From Home," dated 4/24/13, stated "All patients must be screened for medications in their possession at the time of admission." Additionally, the policy stated "Illicit medications may not remain in patient possession."

The consent form for admission and treatment titled "Conditions of Admission to Kootenai Health," is a form signed by patients and or their representative. The form included a paragraph titled "Illegal Drugs." It stated "Substance abuse is prohibited in all areas of KH and I agree to turn over any and all illegal substances. I understand that if I am suspected of possessing an illegal substance or illegal contraband, KH has the right to search me and/or my belongings and seize such items, and I consent to such search and seizure." The facility failed to ensure the policy was implemented, as follows:

Patient #3 was a [AGE] year old male who was admitted on [DATE] for care related to an abdominal abscess and ruptured diverticulitis. He had a history of drug abuse and recent methamphetamine use.

Patient #3's record included educational needs on his admission assessment. The assessment also listed barriers to learning, which included communication, cultural, pain, and substance use.

Patient #3's record documented he was scheduled for a procedure in the radiology department on 12/01/14. A consent was signed by Patient #3 for the placement of a catheter to drain his abdominal abscess. The consent form stated moderate sedation would be used.

Patient #3's record noted that upon his arrival for the procedure, his blood pressure was low, and he was drowsy. Patient #3's blood pressure was 149/73 when he was admitted on [DATE] at 8:47 PM. His blood pressure at 5:40 AM on 12/01/15 was 115/68. When he arrived in the procedure room at 7:55 AM his blood pressure was 99/45.

The RN documented Patient #3 was drowsy and taking his own pain medications. She stated in her note "Pt came to CT for a procedure. Pt was able to answer questions. Pt drowsy would fall asleep after answering questions. MD came and spoke with pt, all questions and concerns answered. MD and myself asked pt if he has been given any pain medications. He said no. When we asked him if he is taking his own medications he stated yes. When asked what they are he was unable to tell us. Due to his vs [vital signs], drowsiness, history of recent meth use, and inability to tell us what medications he is taking we were unable to sedate him for the procedure for his own safety."

The radiologist wrote "The patient was somnolent. Oriented to person, place and time. Understood the procedure, asked an appropriate question and answered direct questions. Medication record was reviewed. No significant pain medications currently per hospital records. Patient was mildly 'giddy'. Nursing [and I] suspected self medication and asked, 'have you been taking her [sic] home medications while in the hospital?' He said 'yes I am.' I suspect opioids. I explained limitedly that we would use lidocaine only."

There was no documentation that indicated staff made efforts to determine what legal or illegal substances Patient #3 had taken that may have impacted his condition or caused him to be drowsy or lower his blood pressure. There was no documentation a drug screen had been completed prior to the procedure.

Patient #3's blood pressure during the procedure was documented, as follows:

- 8:00 AM, 90/51
- 8:05 AM, 88/60
- 8:15 AM, 96/44
- 8:20 AM, 99/45
- 8:25 AM, 99/57
- 8:35 AM, 98/53

Patient #3 returned to the nursing unit at 8:40 AM. The RN who received report and provided his care on the nursing unit documented "When pt arrived back from radiology, pt was asleep and showing no signs of pain; no grimacing, no moaning. I attempted to wake the pt several times and he was very hard to arouse, and pt still showed no signs of pain."

Patient #3 admitted to self medication, however, it was not determined what medication he took, or when it was self administered. His record did not include further investigation to determine if further self medication would be possible.

The RN who provided care for Patient #3 during his procedure on 12/01/14, was interviewed by phone on 10/29/15 beginning at 11:40 AM. She stated Patient #3 claimed his girlfriend brought in his medications. She stated the radiologist asked Patient #3 if he wanted to reschedule the procedure, but Patient #3 stated he wanted it done then. The RN stated Patient #3 was not acting "right," he was vague in his responses, and had admitted to recent methamphetamine use. The RN stated the procedure was completed, and when she gave report to Patient #3's RN on the nursing unit, she told the RN that she would need to follow up and make sure illegal substances were not brought in to the hospital.

There was no documentation in Patient #3's record to indicate nursing staff followed-up after the radiology procedure to search for illegal substances as recommended. The RN who provided care to Patient #3 on the nursing unit was no longer employed, and unavailable for interview.

During an interview on 10/28/15 beginning at 10:15 AM, the Patient Advocate reviewed Patient #3's record and confirmed his record did not include documentation of further investigation of medications brought in that were not ordered by his physician.

The facility failed to ensure efforts to determine what substances Patient #3 may have taken or may have in his possession were documented necessary to ensure he received care in a safe setting.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, medical record review, and staff interview, it was determined the hospital failed to ensure that RNs provided supervision to ensure care standards were met for 4 of 8 medical/surgical patients (#2, #4, #17, and #23) whose records were reviewed. This failure resulted in patient care needs such as hygiene, linen changes, bathing, and assistance with meals not being met. Findings include:

1. During an interview on 10/28/15 at 2:15 PM, a CNA discussed his patient care routine. He stated early in the shift was devoted to taking vital signs, then assistance with meals. He stated patient hygiene was offered around mid-morning, and linens would be changed during that time as well. The CNA stated patients were allowed to decline bathing, and he would try to offer it again during his shift. The CNA stated if he had time, he would try to assist patients with ambulation.

Patient records were reviewed. The records did not included documentation that care standards were consistently met, as follows:

a. The facility's "Insertion and Care of Indwelling Urinary Catheter," effective 5/27/11, it stated "Indwelling catheters will be removed as soon as possible to decrease the risk of infection." The policy stated perineal care was to be performed daily, and the drainage bag was to be emptied at least every 12 hours.

During an interview on 10/28/15 beginning at 8:11 AM, a Patient Advocate who was an RN, stated the standard of care for patients included foley care 3 times daily and as needed.

Patient #2 was a [AGE] year old female who was admitted to the facility on [DATE] for care related to [DIAGNOSES REDACTED] and was discharged on [DATE].

Patient #2 lived in a rural community and was transferred from another facility at approximately 5:00 AM on 7/08/14. She was legally blind, had a diagnosis of [DIAGNOSES REDACTED]. The catheter was discontinued on 7/11/14, the morning of her discharge. Her record did not include documentation foley care was provided at any time during her hospitalization .

During the interview on 10/28/15 beginning at 8:11 AM, the Patient Advocate confirmed Patient #2's record did not include documentation of foley care. She stated foley care should be documented at least every shift.

Additionally, the facility's "Insertion and Care of Indwelling Urinary Catheter," effective 5/27/11, included a section titled "Removal of Catheter, Nurse Driven Protocol." The protocol stated "Need for the urinary catheter should be reviewed on a daily basis. If patient does not meet any of the criteria listed above, or have a specific order from the LIP to leave the urine catheter in place, the nurse will discontinue the catheter and document removal in the chart."

Patient #2's admission orders did not include an order for the urinary catheter. Her record included an order by her physician on 7/11/14, to discontinue the catheter. The nursing staff did not document on a daily basis if her need for a catheter had been assessed in accordance with the "Nurse Driven Protocol."

Patient #2's record was reviewed by a Patient Advocate on 10/28/15 beginning at 8:11 AM. She confirmed there was no documentation related to a daily evaluation for removal of Patient #2's catheter.

The facility failed to ensure foley care was provided routinely and that its use was evaluated daily.

b. During an interview with the Patient Advocate on 10/28/15 beginning at 8:11 AM, she stated ostomy output was to be measured at least every shift, as with other output measurements.

Patient #2's record documented she had an illeostomy, and she had an appliance attached. The appliance was documented as changed by the wound care team on 7/09/14. Ostomy assessment and output was not documented until 7/11/14, when it was emptied on 3 occasions, for a total of 330 ml output.

During an interview with the Patient Advocate on 10/28/15 beginning at 8:11 AM, she confirmed Patient #2's ostomy output was not recorded until 7/11/14.

The facility failed to ensure ostomy care was provided routinely.

c. A policy related to provision of patient hygiene was requested but not submitted by the facility. However, during an interview on 10/28/15 beginning at 8:11 AM, a Patient Advocate who was an RN, stated the standard of care for patients included offering a bath twice daily. She was not able to state the standard of care for oral care, but said she thought it was twice daily as well.

i. Patient #4 was an [AGE] year old female, admitted on [DATE] for care related to an irregular heartbeat. She was discharged on [DATE]. Her record did not include documentation that she was offered a bath during her hospitalization . Her record included oral care, provided on 2/16/15 at 9:13 PM.

During an interview on 10/28/15 beginning at 9:52 AM, the Patient Advocate reviewed Patient #4's record and confirmed there was no documentation a bath was offered or provided. Additionally, she confirmed that oral care was not documented.

ii. Patient #2's record was reviewed for bathing. One bath was documented in four days as follows:

- 7/08/14 at 9:00 AM, bathing notes stated a bath was not given due to "clinical judgement."

- 7/08/14 at 9:00 PM, bathing notes stated "refused."

- 7/09/14 at 9:00 AM, a bed bath was documented.

- 7/09/14 at 9:00 PM, bathing notes stated "asleep."

- 7/10/14 at 9:00 AM, bathing notes stated "refused."

- 7/10/14 at 10:00 PM, bathing notes stated "asleep."

- 7/11/14, no bath was documented.

During the interview on 10/28/15 beginning at 8:11 AM, the Patient Advocate confirmed Patient #2 received one bath. She stated the staff generally worked 12 hour shifts, and the night shift bathing was usually around 9-10 PM. She stated the first part of the shift included vital signs and assessments. The Patient Advocate confirmed the time was late for a patient in her 90's, and stated she probably would not want to be awakened and offered a bath at that time as well. The Patient Advocate was unable to determine what the RN meant when it was documented no bath was given on 7/08/14, due to "clinical judgement."

The facility failed to ensure oral care and bathing was provided routinely.

d. During the interview on 10/28/15 at 8:11 AM, the Patient Advocate, an RN, explained that non-select was a term for the dietary department to know that the patient does not or cannot select their own choices for meals. She stated the dietary department would send up meals for those patients at 7:30 AM, 11:30 AM, and 4:30 PM. The Patient Advocate stated meals were delivered by a dietary worker, and it was the responsibility of the RN or the CNA to ensure the patients were set up and/or assisted with each meal.

Patient #2's record included information that she was "Non-Select" for room service. Her record included documentation that on 7/08/14 at approximately 3:30 PM, she was scheduled for an ERCP (Endoscopic retrograde cholangiopancreatography, a specialized technique used to study the bile ducts, pancreatic duct and gallbladder). After the procedure was completed, her physician ordered a clear liquid diet with the notation she could advance as tolerated to a regular diet.

However, Patient #2's record documented only 3 meals in the 4 days she was hospitalized (from 7/08/14 - 7/11/14), as follows:

- 7/08/14: NPO as ordered for breakfast and lunch. Dinner was not documented.

- 7/09/14: Breakfast, lunch and dinner were not documented, however, at 6:41 PM, her nurse noted she had cereal, soup and juice.

- 7/10/15: She ate 50% of breakfast, 75% of lunch, and nothing was recorded for dinner.

- 7/10/14: She ate 5% of breakfast and was discharged around noon that day.

Patient #2's record was reviewed on 10/28/15 at 8:11 AM with a Patient Advocate. She confirmed that of the 4 days she was hospitalized only 3 meals were documented.

e. During an interview on 10/28/15 beginning at 8:11 AM, a Patient Advocate who was an RN, stated the standard of care for patients included daily ambulation as tolerated.

Patient #2's 7/8/14 admission orders included an order for PT to evaluate and treat. Her physician ordered her activity as "Up with assist." On 7/09/14, she was evaluated by a physical therapist. She was documented as ambulating in the hall with assistance of the therapist while using a walker. The evaluation included documentation that she would be seen by therapy daily Monday through Friday, and as needed on weekends. However, no further physical therapy visits were noted in her record. The nursing staff did not document assistance with ambulation beyond getting her up to a chair on 7/8/14 at 1:00 PM and 8:00 PM, on 7/9/14 at 6:24 PM and on 7/10/14 at 6:00 PM.

Patient #2's record was reviewed on 10/28/15 at 8:11 AM with a Patient Advocate. She confirmed Patient #2's record did not include further ambulation beyond the initial PT assessment on 7/09/14.

f. During an interview on 10/28/15 beginning at 8:11 AM, a Patient Advocate who was an RN, stated the standard of care for patients included linen changes were to be offered daily, with a minimum of every other day changes.

i. Patient #2's record did not include documentation her bedding/linen had been changed during the 4 days she was hospitalized (from 7/08/14 - 7/11/14).

This was confirmed by the Patient Advocate on 10/28/15, at 8:11 AM.

ii. Patient #4's record did not include documentation of a linen change during her hospitalized from [DATE] until 2/18/15. This was confirmed with the Patient Advocate on 10/28/15 at 9:52 AM.

iii. Patient #17 was a [AGE] year old male admitted on [DATE] for care related to [DIAGNOSES REDACTED]. He was transferred from ICU to the medical floor on 10/26/15 at 9:36 PM.

Patient #17's record documented linens were changed when he was in ICU on 10/24/15 at 12:41 PM, but no further entries of linen changes were noted, from 10/24/15 to 10/28/15, when his record was reviewed.

The Patient Advocate and Nurse Manager were present at the time of Patient #17's record review on 10/28/15 at 2:00 PM, and confirmed linen changes were not documented for 4 days.

iv. Patient #23 was a [AGE] year old male who was admitted on [DATE], for care related to sepsis. Additional diagnoses included [DIAGNOSES REDACTED].

Patient #23's record was reviewed with a Patient Advocate on 10/29/15 at 8:15 AM, and she confirmed there was no documentation of linen changes.

The facility failed to ensure linens were changed routinely.

During an interview on 10/28/15 beginning at 2:00 PM, the Nurse Manager stated he did not routinely audit patient records for documentation of patient hygiene activities. He stated he made daily rounds and spoke with patients and their family members. He stated he asked direct questions related to hygiene and other activities, and if there was a question as to inadequate cares or patient concerns, he would review the patient records. The Nurse Manager stated he did not use an audit tool to ensure the activities were consistently performed.

The registered nurses did not supervise and evaluate patient care to ensure care standards were met.





2. Refer to A-0144 as it relates to a failure of nursing staff to ensure patient records comprehensively documented all interventions taken to ensure care was provided in a safe setting.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, medical record review, and staff interview, it was determined the hospital failed to ensure a plan of care was developed and updated for 3 of 8 medical/surgical patients (#2, #18 and #23) whose records were reviewed. This resulted in a lack of direction to nursing staff and delivery of patient care. Findings include:

A policy for nursing care planning was requested. The Regulatory Compliance Coordinator provided a policy titled "Plan of Care/Nursing Services," dated 10/03/14.

The policy stated the role of the RN is to provide/oversee the care given to the patients that they are assigned and to assure that care is collaborative, compassionate and high quality as defined by unit, [the facility,] and evidence based standards. The policy further stated that CNA's are utilized to assist patients with activities of daily living and to carry out other duties as delegated by the RN. The policy did not include the development of nursing interventions related to the patients' individualized needs. Additionally, the policy did not include how the plan of care would be updated to ensure it was appropriately addressing the patients' response to interventions.

The hospital did not ensure the nursing care plan addressed patient specific needs in the following examples:

1. Patient #2 was a [AGE] year old female who was admitted to the facility on [DATE] for care related to [DIAGNOSES REDACTED]. She was legally blind, had a diagnosis of [DIAGNOSES REDACTED]

Patient #2's record documented she had macular degeneration and was legally blind. She was noted as living independently, with family close by. She used a walker for ambulation. A PT evaluation documented Patient #2 had received assistance in the mornings (prior to admission) with the care of her colostomy, and her family assisted her in the evenings. Patient #2 was transferred from another hospital, and she was admitted directly to the nursing unit on 7/08/14 at 5:19 AM. She had a urinary catheter and an IV in place upon her admission.

Patient #2's record included a form titled "Plan of Care Problems," created by the RN at the time of her admission assessment. The form included dates and times of edits, and was an active working problem list during her hospitalization . The problem list included potential and actual problems that were identified. Throughout her record, the problems were addressed with interventions and assessments. However, Patient #2's problem list did not include her blindness, colostomy, foley catheter, or ambulation needs. As a result, there were no interventions in place to address her individualized nursing needs.

a. Patient #2 had an indwelling urinary catheter. However foley care was not included in her nursing care plan. Her record did not include documentation foley care was provided at any time during her hospitalization . Additionally, the nursing care plan did not include the "Nurse Driven Protocol" to assess if criteria had been met for urinary catheter removal. Patient #2's medical record did not include documentation that she was assessed daily for evaluation if the urinary catheter could be discontinued.

b. Due to her blindness, Patient #2 was unable to read the menu or call and select her meals. Her record indicated she was "Non-Select," which resulted in the dietician selecting her meals and sending them at specific times of the day. Her nursing care plan did not include interventions to address her dietary needs, such as assistance with meals or meal set up due to her blindness. Patient #2 was NPO for breakfast and lunch on 7/08/14, after her procedure was completed, her physician ordered her diet to be advanced as tolerated. During the remainder of Patient #2's hospitalization , her record documented intake for 4 of the possible 8 meals.

c. A PT assessment was performed on 7/09/14. The assessment indicated Patient #2 was able to ambulate with minimal assistance. However, Patient #2's nursing plan of care did not include the intervention to assist Patient #3 with ambulation. Her medical record did not include documentation nursing staff assisted with ambulation. Her activity noted she was up to a chair.

d. Patient #2's nursing care plan did not include ostomy care. Her record indicated her ostomy appliance was changed on 7/09/14 by the wound care team. Ostomy outputs were not recorded until 7/11/14, the day she was discharged .

During an interview on 10/28/15 beginning at 8:11 AM, the Patient Advocate, an RN, reviewed Patient #2's record and confirmed the nursing care plan was not comprehensive and individualized.

2. Patient #18 was a [AGE] year old male who was admitted on [DATE] for care related to chest pain. He had a skin graft on his right thigh and a wound on his right calf. His toenails were documented as being thick with fungus present. His groin was excoriated, with infected scabs noted. His wounds were positive for MRSA, and he was in contact isolation. Additional diagnoses included [DIAGNOSES REDACTED]

Patient #18's record included multiple documentation entries of apathy, flat affect, refusing bathing, and non-compliance with ADL's. However, his nursing care plan and problem list did not include interventions to meet his needs and allow him to be more compliant with his care.

During an interview on 10/28/15 beginning at 9:30 AM, the Patient Advocate reviewed Patient #18's record and confirmed his nursing care plan did not address his psycho-social needs and non-compliance.

3. Patient #23 was a [AGE] year old male who was admitted on [DATE], for care related to sepsis. Additional diagnoses included [DIAGNOSES REDACTED]

Patient #23's nursing care plan did not include ostomy care. His record included documentation the appliance was changed on 10/20/15 at 1:02 PM.

During an interview on 10/29/15 beginning at 8:15 AM, the Patient Advocate reviewed Patient #23's record and confirmed his plan of care did not address ostomy care.

The hospital did not ensure the nursing care plan addressed patient specific needs.
VIOLATION: SUPERVISION OF EMERGENCY SERVICES Tag No: A1111
Based on review of the hospital's organizational chart and staff interview, it was determined the hospital failed to ensure emergency services were supervised by a qualified member of the medical staff. This resulted in an RN Director providing day to day supervision of emergency services and unclear medical staff supervision. Findings include:

The hospital's organizational chart was reviewed and identified an RN Director of Emergency Services. The (RN) Director of Emergency Services was interviewed on 10/28/15 beginning at 8:00 AM. She stated physicians were present 24/7, working in the ED providing patient care, however, they did not function in a supervisory role.

The Manager of the Medical Staff was interviewed on 10/28/15 at 1:15 PM. She stated the hospital had not privileged any ED physicians to supervise emergency services.

The Chief of Staff and a contracted ED physician were interviewed together on 10/28/15 at 3:45 PM. The Chief of Staff stated he would begin the process of privileging ED physicians to supervise the ED.

The emergency services were not supervised by a qualified member of the medical staff.