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.

MOUNTAIN VIEW CENTER FOR GERIATRIC PSYCHIATRY 500 POLK STREET EAST KIMBERLY, ID Nov. 20, 2014
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview, and review of medical records and facility policies, it was determined the hospital failed to ensure the Advance Directives of 3 of 3 patients residing in the facility during the survey (Patients #1, #2, and #3) were clearly and immediately identifiable, accurate, and authenticated. This resulted in the potential for lack of, or delayed, implementation of life-saving measures; or the provision of life-saving care contrary to the wishes of the patient or responsible party. Findings include:

1. Patient #1 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of dementia with behavioral disturbance, and psychosis. He was admitted to the facility involuntarily at the direction of the state, pending legal proceedings.

Patient #1's medical record included a form titled, "IDAHO PHYSICIAN ORDERS FOR SCOPE OF TREATMENT" (POST). Section A of the form included a check mark next to "Do Not Resuscitate (No Code): Allow Natural Death; Patient does not want any heroic or life-saving measures." The POST form was signed by Patient #1's son on 10/03/14, and signed by his physician on 10/21/14.

The facility utilized green binders to hold medical records for current patients. Each patient's binder was labeled with the patient's name, physician's name and date of admission. The front of Patient #1's binder included a bright green sticker labeled "ADVANCE DIRECTIVES". The label included a check mark next to "DO NOT RESUSCITATE" and "DURABLE POWER OF ATTORNEY FOR HEALTH CARE". The word "Committed" was hand written on the bright green label.

During an interview on 11/18/14 at 10:00 AM, the DON stated when a patient is admitted to the facility on on an involuntary status, they have to be a full code, meaning in the event of cardiac or respiratory arrest, resuscitation efforts would be initiated and emergency medical services called for transport to an acute care hospital.

During an interview on 11/18/14 at 10:15 AM, the RN assigned to Patient #1 was asked about his status related to resuscitation. She looked at his POST form and stated it was "Do Not Resuscitate". She was then asked why the word "Committed" was written on the bright green sticker on the front of his record. She stated, "I think if they are committed they are a full code, but I'd have to check the policy." She looked through the legal documents in Patient #1's record for 8 minutes, and then stated, "I'm not sure. I'd have to read all this."

Johns Hopkins Medicine website, accessed 11/24/14, stated when cardiac arrest occurs, "Response time is critical, with the death of all other brain and bodily functions occurring in just four to six minutes following cardiac death ... After ten minutes, survival is unlikely".

The RN was asked how she would proceed if she found Patient #1 on the floor without a pulse or respirations. She stated she would check his wrist band to determine his resuscitation status, so she would not have to walk away from him.

On 11/18/14 at 11:05 AM, Patient #1's wrist band was examined. It did not include his resuscitation status.

During an interview on 11/18/14 at 10:25 AM, the Director of Social Services stated Patient #1's situation was unusual. She stated he had a guardian assigned by the state to make decisions related to his medical care, however, the guardian allowed Patient #1's son to make the decision related to his resuscitation status. The Director of Social Services reviewed Patient #1's record and was unable to find documentation stating the son was authorized to determine his resuscitation status. She stated she did not know why the word "Committed" was written on the sticker and she confirmed it resulted in confusion to the facility staff as to Patient #1's resuscitation status.

Patient #1's resuscitation status was not clearly documented to allow the facility staff to respond appropriately in the event of cardiac or respiratory arrest.

2. Patient #3 was a [AGE] year old female admitted to the facility on [DATE], for psychiatric care related to acute manic phase of her bipolar disorder.

Patient #3's medical record included a form titled, "IDAHO PHYSICIAN ORDERS FOR SCOPE OF TREATMENT" (POST). Section A of the form included a check mark next to "Resuscitate (Full Code)". The POST form did not include patient or physician signatures.

The front of Patient #3's binder included a bright green sticker labeled "ADVANCE DIRECTIVES". The label included a check mark next to "DO NOT RESUSCITATE" or "DNR."

During an interview on 11/18/14 at 10:30 AM, the Director of Social Services and the DON reviewed Patient #3's record. They both confirmed the green sticker on the front of her record indicated she was a "DNR." The DON stated she did not know why the sticker indicated DNR, as she was on a Designated Examiner Hold status, and was a full code according to the facility policy. The Director of Social Services confirmed her response and stated the sticker should not have indicated DNR.

The resuscitation status indicated on Patient #3's medical record was incorrect.

3. Patient #2 was a [AGE] year old male admitted to the facility on [DATE] for psychiatric care related to schizophrenia with acute exacerbation and psychosis.

Patient #2's medical record included a form titled, "IDAHO PHYSICIAN ORDERS FOR SCOPE OF TREATMENT" (POST). Section A of the form included a check mark next to "Do Not Resuscitate (No Code): Allow Natural Death; Patient does not want any heroic or life-saving measures." The line next to "Patient/Surrogate Signature" was blank. The physician signature line was signed by the psychiatric NP, and dated 9/12/14.

The POST form indicated the basis for the Do Not Resuscitate order was the patient's known preference and his living will, however his medical record did not include a living will document.

A hand-written note at the bottom of the form stated the form was discussed with Patient #2's spouse on 9/10/14, which was the day before he was admitted to the facility. However, Patient #2's medical record did not contain documentation to indicate an attempt had been made to obtain his wife's signature on the form.

During an interview on 11/18/14 at 10:40 AM, the Director of Social Services and the DON reviewed Patient #2's record, and confirmed the POST did not include a signature from his spouse. The Director of Social Services stated when a family member is unable to sign the admission and other paperwork, a packet of forms to be signed would be mailed. She stated that probably occurred, and the wife of Patient #2 probably did not return the paperwork. However, she was unable to provide evidence that Patient #2's spouse was sent the paperwork to be signed.

Patient #2's POST form was not signed by the patient or responsible party.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records and staff interview, it was determined the hospital failed to ensure psychiatric treatment and interventions to treat depression were provided for 1 of 3 patients (Patient #1) residing in ther facility during the survey. This resulted in potentially unnecessary mental anguish and neglect. Findings include:

Patient #1 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of dementia with behavioral disturbance, and psychosis. He was admitted to the facility involuntarily at the direction of the state, pending legal proceedings.

Patient #1's medication sheet included Wellbutrin (an antidepressant) 150 mg daily, ordered on [DATE]. The dose was increased to 300 mg daily on 11/11/14. A progress note, written on 11/16/14, and signed by the psychiatric Medical Director, stated he discontinued the Wellbutrin because it was not helpful and may be causing loss of appetite.

An Interdisciplinary Group (IDG) note, dated 11/11/14, stated Patient #1 continued to report being depressed. A progress note, written on 11/16/14 and signed by an RN, included "[Psychiatric Medical Director] in on rounds. Tried to speak with pt, but pt would only shrug one shoulder or nod. [Psychiatric Medical Director] asked pt if he was feeling more upbeat and pt shook head no. Asked if he was still feeling sour and pt shook head yes."

An Interdisciplinary Group (IDG) meeting was observed on 11/18/14 at 1:00 PM. The attendees included the psychiatric Medical Director, the medical physician, the psychiatric NP, the DON, the Director of Social Services, the dietician, the pharmacist and an RN.

During the IDG meeting the psychiatric Medical Director stated he had prescribed Wellbutrin to treat Patient #1's depression. He stated he discontinued the Wellbutrin because it was causing decreased appetite and increased agitation. Additionally, the Medical Director told the group that he had a conversation with Patient #1, and told him that it would be in his best interest to not make passes at women in the future. The psychiatric Medical Director stated, "We could try other antidepressants but we're beyond that." He stated Patient #1 would be kept in a facility or in jail due to his legal situation.

Patient #1's medical record did not include a care plan related to depression.

During an interview on 11/20/14 at 11:00 AM, the Administrator stated he did not know Patient #1's depression was not being treated. He stated if he was aware he would have questioned the psychiatric Medical Director. Additionally he stated, "That's not what we are about."

Further efforts to treat Patient #1's depression were not pursued.