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 April 29, 2021
VIOLATION: INFECTION CONTROL LOG Tag No: A0750
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, review of CDC website, and staff interview, it was determined the hospital failed to ensure staff followed effective infection prevention practices for patients with identified transmissible infections. This directly affected 1 of 1 patient (Patient #2) who had an identified transmissible infection and whose record was reviewed, and had the potential to affect all patients. Findings include:

Patient #2 was a [AGE] year old male admitted on [DATE], with a primary diagnosis of schizophrenia, paranoid type. He was discharged from the hospital on [DATE].

Patient #2's record included an ED physician note, dated 4/16/21 at 1:16 PM, signed by a physician. The note stated a physical exam revealed, "Erythematous patch of rash to the right oral commissure and cheek measuring around 3 cm [centimeters] in diameter with superimposed honey colored crusting consistent with impetigo." The physician ordered an antibiotic to treat Patient #2's impetigo.

The CDC website, accessed 5/03/21, stated, "Impetigo is a superficial bacterial skin infection that is highly contagious ... Streptococcal impetigo is most commonly spread through direct contact with other people with impetigo ... Crowding, such as found in schools and daycare centers, increases the risk of disease spread from person to person."

Patient #2's record did not include a physician's order for contact precautions. His care plan did not include isolation or other precautions to prevent the spread of impetigo to staff and other patients.

During an interview on 4/29/21 at 1:00 PM, the BHU Director reviewed Patient #2's record and stated a diagnosis of impetigo required contact isolation. She confirmed there was no physician order for contact isolation and no documentation of contact precautions for Patient #2.

The hospital failed to ensure proper precautions were taken to prevent the spread of infectious disease.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy and grievance documentation and staff interview, it was determined the hospital failed to ensure written responses were complete or sent to patients with grievances for 2 of 6 complaints and grievances that were reviewed. Findings include:

A "Patient Grievance Policy," dated 11/26/19, included the following information:

- "When the patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to another staff member for later resolution, requires investigation, and/or requires further actions for resolution then the complaint is a grievance."

- "All formal and informal grievances will be investigated to determine if opportunities exist to improve processes and systems related to the issues reported."

- "The hospital "will send written communication to the patient and/or the patient's representative within 7 days of the receipt of the grievance. This written communication shall outline the results of the investigation and actions taken therein."

This policy was not followed. Examples include:

1. Patient #4 was a [AGE] year old female, admitted on [DATE]. The hospital received a grievance letter from Patient #4, with allegations related to medical staff misconduct and nursing staff misconduct. Grievance documentation and a letter of response, dated 10/01/20, documented medical staff concerns were referred to the medical staff office for a confidential review. The grievance documentation and letter of response did not address any investigation or actions taken related to allegations of nursing misconduct (failure to assess for drug intolerances and failure to disclose information related to a new medication prior to administering it to her).

The Director of Employee and Guest Experience and the Patient Advocate were interviewed together on 4/28/21 at 10:00 AM. They confirmed the letter of response to Patient #4's written grievance letter, dated 10/01/20, did not address the nursing allegations.

The hospital's letter of response to Patient #4's grievance was incomplete.

2. Patient #5 was a [AGE] year old female, admitted on [DATE].

Grievance documentation indicated Patient #5 contacted Patient Advocacy to complain about medical staff treatment and failure of a physician to provide information regarding her diagnosis. This was a potential patient rights violation, which qualified as a grievance. There was no documentation to indicate her allegations were investigated and no letter of response to an investigation.

The Director of Employee and Guest Experience and the Patient Advocate were interviewed together on 4/28/21 at 10:00 AM. They stated Patient #5's concerns were classified as a complaint rather than a grievance because they felt it was dealt with in real time. They stated her concerns were referred to the medical staff.

By definition, if a complaint investigation requires a referral, it is considered a grievance, and subject to grievance requirements.

Patient #5's grievance was misclassified as a complaint and no letter of response was provided.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**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 patients were included in their plan of care for 2 of 7 patients (#2 and #4) whose records were reviewed. This resulted in a patient's requests and preferences related to medications and possible transfer not being considered and a lack of patient involvement in the plan of care. Findings include:

1. The hospital's "Patient Rights & Responsibilities" brochure, dated 4/03/18, included the following information:

- "As a patient, you are entitled to participate in decisions about your care, treatment and services provided to you."

Patient #4 was a [AGE] year old female, admitted on [DATE], for suicidal ideation. She was placed on an administrative involuntary hold by a physician on 8/12/20, based on being a danger to herself. DE evaluations, conducted on 8/13/21 and 8/14/21, concluded Patient #4 was still at risk of self-injury, and her involuntary hold was extended. A DE evaluation, conducted on 8/18/20, concluded Patient #4 was no longer likely to injure herself. She was released from an involuntary hold at that time and discharged on [DATE].

Patient #4 was not sufficiently included in her plan of care. Examples include:

A. Request for brand name Synthroid Instead of generic Synthroid (Levothyroxine)

A nurse shift summary for Patient #4, dated 8/15/20 at 1:39 PM: "Pt ...upset that she has a headache and stomach ache/nausea, she blames this on taking generic levothyroxine this AM,..."

A nursing note for Patient #4, dated 8/17/20 at 7:04 AM, stated Patient #4 "refused Synthroid d/t [due to] it not being 'name brand' and has different fillers and dyes in it. Requests to be able to get the name brand or to get it from her pharmacy."

A nursing note for Patient #4, dated 8/17/20 at 10:46 AM, stated "Pt was somewhat pressured in her speech this morning, concerned that her Synthroid needs to be name brand for her to take it. She stated that she is highly sensitive to medications and her Neurologist in New York prescribed her the name brand. Pt reported that the generic brand gave her a migraine for 4 days."

A provider note for Patient #4, dated 8/17/20 at 10:56 AM, stated, "Patient demanding to receive brand Synthroid. Patient gave me the phone number of her neurologist in Rochester New York. I attempted to call him and he is retired. Patient claims generic Synthroid gives her headaches and GI distress. This appears to be a concern I have in terms of control issues and some appetizing but we will address with our pharmacy." "I checked with pharmacy and we do not have brand Synthroid."

A provider note for Patient #4, dated 8/18/20 at 10:36 AM, stated, "I informed patient that her physician who she stated was treating her previously in Rochester New York with Synthroid is retired. Inform patient that we would be very happy to continue to offer her the Synthroid that is available at our hospital. Patient refusing. This clearly appears to be part of a control/somatic response by patient." "Patient stated she will not take generic Synthroid..."

A policy, "Medication Management," dated 8/31/20, stated "Non-formulary items are to be purchased only for a specific patient."

A hospital pharmacist was interviewed by telephone on 4/29/21 at 11:00 AM. He stated the pharmacy could order brand name Synthroid. "I would get a 10 day supply for a specific patient, if requested." He stated it was possible to put an alert in the system "brand name only" to avoid giving a generic equivalent. He stated as an alternative to ordering a brand of medication, the patient could have her own medication brought in and administered after appropriate vetting. When asked if a patient could react to a generic form of a drug, he stated it could happen in rare cases.

Patient #4's request to have brand name Synthroid instead of the generic (that she believed was triggering headaches) was not honored, despite the hospital's processes in place to honor her request.

B. Medication Alternative to Zyprexa

A provider note for Patient #4, dated 8/16/20 at 12:21 PM, stated "...when offered Zyprexa has refused stating it could lead to weight gain." Under "Assessment and Plan: "Will initiate standing Zyprexa..."

A nurse shift summary for Patient #4, dated 8/16/20 at 8:35 PM, stated she "Refused to take scheduled or prn Zyprexa, 'that stuff will make me gain weight, I won't take it.'"

A nursing note for Patient #4, dated 8/17/20 at 10:46 AM, stated "Pt declined PRN Zyprexa stating that her son gained 120 pounds on it and she has a history of high blood sugar, so she was not willing to take that. She did say that she was willing to try a different antipsychotic."

A provider note for Patient #4, dated 8/17/20 at 10:56 AM, stated, "...when offered Zyprexa patient is concerned about weight gain." and "Patient refused her ...Zyprexa. With regard to Zyprexa patient is concerned about weight gain but as noted patient has been requesting Ensure."

There was no documentation Patient #4's concerns related to side effects were addressed or that she was offered an alternative to Zyprexa that would not cause weight gain.

The Director of BHU was interviewed on 4/29/21 at 10:20 AM. She reviewed Patient #4's record and was unable to point out where Patient #4's concern regarding Zyprexa was addressed.

Patient #4's request for an alternative to Zyprexa, that did not have weight gain as a side effect, was not addressed.

C. Transfer Request

Patient #4 made multiple requests to transfer to a different facility.

A nursing shift summary, dated 8/12/20 at 7:25 PM: "Pt was labile and frustrated this evening. Pt expressed her frustration with the doctor stating, 'He said he couldn't help me so I am not going to cooperate with anything. I want to go to a different hospital.'"

A therapist note, dated 8/13/20 at 9:50 AM: "OFFERED PT OPPORTUNITY TO REVIEW AND SIGN TREATMENT PLAN. PT REFUSED STATING "I WILL NOT SIGN A TREATMENT PLAN FROM THIS HOSPITAL, I HAVE ASKED TO TRANSFER TO ANOTHER HOSPITAL."

A nurse shift summary, dated 8/13/20 at 1:47 PM, quoted Patient #4 as saying "...I would like to transfer to a different hospital..."

A provider note for Patient #4, dictated 8/13/20, and labeled " hospitalization DAY 2", stated "She continues to vilify multiple nurses and this physician stating that she wants to transition to a different hospital, because she believes we will cause her harm here."

A case management note, dated 8/14/20 at 3:48 PM stated, "Called patient advocacy on behalf of patient as she has multiple complaints about the hospital including wanting to transfer and wanting a different doctor, not being treated well or fairly here. This is very different presentation from her last stay with us and I want to make sure to take her concerns seriously."

A psychiatry consultation note for Patient #4, dated 8/14/20, dictated at 5:30 PM, stated, "She had been ambivalent about her admission to this facility and has wanted to transfer elsewhere when she did not agree with care that was being recommended or provided. That was not an option, and she demanded to leave the hospital, so she was placed on an involuntary hold because she was still stating that she was suicidal."

The Director of BHU provided a copy of Idaho Statue, Title 66, "hospitalization of Mentally Ill." It stated "Nothing in this section shall preclude a hospital from transferring a person who has been detained under this section to another facility that is willing to accept the transferred individual for purposes of observation, diagnosis, evaluation, care or treatment."

During an interview on 4/29/21 at 2:00 PM, the Director of the BHU stated a patient on an involuntary hold could be transferred, however, it was usually not done because "we cannot get anyone to accept." She confirmed there was no documentation Patient #4's request for transfer was considered.

Patient #4's request to transfer to another hospital was not considered or addressed.

D. Pain Management

A patient brochure"Patient Rights & Responsibilities," dated 4/03/18, stated "As a patient, you are entitled to appropriate pain management through cooperative planning involving you, your physician, and your nursing staff."

A policy, "Pain Management," dated 3/12/21, included the following information:

- "All patients have the right to safe and effective pain management..."

- "The patient's self-report is accepted as the most accurate measure of the current level of the patient's pain."

- "The interdisciplinary team, patient, & family will collaborate to effect meaningful pain relief for the individual wherein pain is minimized..."

- "For complex pain management concerns, there are additional expert clinical resources such as pharmacists, interventional pain physicians, clinical nurse specialists, and palliative care clinicians."

- "Patient satisfaction with pain management is evaluated on an ongoing basis."

The comprehensive pain assessment included "... Any pain relief methods that have proven effective ... The patient's pre-hospitalization history of pain, analgesic use, response to pain therapy, medication tolerance & history of substance abuse"

Patient #4's pain assessments and interventions provided were documented as follows:

8/12/20 12:48 AM - Denies pain
8/12/20 11:34 AM - Denies pain
8/12/20 6:15 PM - Denies pain
8/13/20 9:00 AM - Reports pain in head and hips (pain not rated); "Distraction, Medication Refused, Rest"
8/13/20 2:51 PM - Reports headache as a 9 on a scale of 0-10; "Cool cloths, Distraction, Medication, Rest"
8/13/20 3:43 PM - Post-assessment report of a headache that remains as a 9; "Cool cloths, Distraction, Rest, Hydration/Encourage fluids"
8/13/20 7:15 PM - Reports headache as an 8; "Cold application"
8/13/20 8:29 PM - Reports headache as an 8; "Cold application"
8/14/20 9:47 AM - Reports headache as a 10; "Medication refused. Pt refused all offered interventions"
8/14/20 5:21 PM - Reports headache as a 10; "Preassessment, Imitrex and Zofran;" "Distraction, Medication, Rest"
8/14/20 6:21 PM - Reports headache as a 10; "Postassessment Imitrex and Zofran"
8/14/20 8:31 PM - Denies pain
8/15/20 10:40 AM - Reports headache as a 10; "Distraction, medication, rest"
8/15/20 10:56 AM - Denies pain
8/15/20 11:30 AM - Reports headache as a 10; "Rest, Hot Application, Cold Application"
8/15/20 5:23 PM - Reports headache as a 10; "Distraction, Medication, Rest, Hydration/Encourage Fluids"
There was no documented post-assessment of pain after administration of pain medication.
8/16/20 8:55 AM - Denies pain
8/16/20 2:14 PM - Reports headache as a 6; "Medication, Cold Application"
8/16/20 3:00 PM - Reports headache as a 3; "Distraction, Rest"
8/16/20 4:00 PM - Denies pain
8/17/20 9:02 PM - Denies pain
8/17/20 6:08 PM - Denies pain
8/17/20 7:50 PM - Reports headache as a 7; "Distraction, medication, rest"
8/18/20 6:06 PM - Denies pain
8/19/20 10:55 AM Denies pain

A provider note for Patient #4, dated 8/14/20, stated Patient #4 "has been complaining of a migraine headache; however, she has refused her oral dose of Imitrex. She was provided IM Toradol and Benadryl; she refused this as well. The patient did make a request for opiates instead."

A provider note for Patient #4, dated 8/15/20 at 12:37 PM, stated, "Patient endorses a headache with a pain level rated at 15 out of 10. Patient's endorsements are not consistent with clinical expectations. Concern for opioid seeking behavior."

A provider discharge note for Patient #4, dated 8/19/20 (untimed), stated, "There were numerous demands that at one point were concerning for the potential for opioid and benzo [benzodiazepene, a class of psychoactive drugs] seeking behavior..."

There was no documentation to indicate Patient #4 was assessed by medical staff or nursing staff, per policy, as to what medications had been effective in the past to treat migraines. There was no documentation she was assessed to have a past history of narcotic abuse, and would be ineligible for narcotic medication. There was no consultation with expert clinical resources, such as pharmacists, interventional pain physicians, clinical nurse specialists, and palliative care clinicians, to deal with complex pain. She reported pain in the 8-10 range on a scale of 0 to 10, on day 2 (8/13/20) through day 4 (8/15/20) of her hospitalization which she believed was triggered by a medication she was given. Her pain was not sufficiently addressed in accordance with hospital policy.

The Director of BHU was interviewed on 4/29/21 at 9:30 AM. She stated it was their general practice to keep providing interventions until pain was relieved. A consult was sometimes necessary. She confirmed Patient #4's report of ongoing severe pain.

There was no documentation Patient #4's pain was managed in accordance with hospital policy.





2. The BHU's policy, "Kootenai Behavioral Health Center Treatment Planning - Youth Acute, Adult Services, and Chemical Dependency," last reviewed 4/23/21, stated, "Patients participate in the development of their treatment plan in the assessment processes, individual sessions, and group therapy. Patients will sign their treatment plan to demonstrate they have reviewed the plan and been given the opportunity to provide input. The patient may suggest amendments to their plan at any time throughout their stay." This policy was not followed.

The packet of information given to patients at admission to the BHU was reviewed. It included a document titled "Program Expectations" with a line for the patient's signature. The document stated, "Your input is very important in developing a therapeutic treatment plan. While a patient on the Adult Unit, you will be expected to attend specific groups as defined by your treatment plan. The groups are an important part of your treatment and are designed to give you support and education to help you move forward toward recovery.

During an interview on 4/29/21 beginning at 9:30 AM, the Case Management Supervisor and the Director of BHU were asked about the BHU's treatment plan. They stated if a patient refused to sign their treatment plan, "The therapist would have a conversation about why they do not want to sign." They stated there must be documentation that the patient refused to sign their treatment plan, including the reason they refused to sign.

Patient #2 was a [AGE] year old male admitted on [DATE], with a primary diagnosis of schizophrenia, paranoid type. He was discharged from the hospital on [DATE].

Patient #2's record included a "Treatment Plan" dated 4/19/21. The plan was signed by a Provider, Charge Nurse, Recreational Therapist, Therapist, and Case Manager. The line for patient signature stated "Refused." It did not include the reason Patient #2 refused to sign his treatment plan. Patient #2's record included a note entered by a therapist, dated 4/19/21 at 2:44 PM. It stated, "Patient refused to complete any paperwork that included treatment plan, safety plan, needs assessment." It did not document a conversation with him regarding his treatment plan or the reason he refused to sign his treatment plan.

During an interview on 4/29/21 at 1:00 PM, the Supervisor of Case Management reviewed Patient #2's record and confirmed there was no documentation of a conversation with him regarding his treatment plan or the reason he refused to sign his treatment plan.

Patient #2 was not involved in his treatment plan.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of patient rights information, record review, and staff interview, it was determined the hospital failed to provide sufficient information to make an informed decision regarding medications for 1 of 7 patients (Patient #4) whose records were reviewed. This resulted in a patient being given a medication to which she had previously had an adverse reaction, without being informed prior to taking the medication. This impacted the patient's right to refuse the medication and had the potential to impact patient safety. Findings include:

1. The hospital's "Patient Rights & Responsibilities" brochure, dated 4/03/18, stated, "As a patient, you are entitled to received sufficient information to give consent prior to treatment except in life threatening situations."

Patient #4 was a [AGE] year old female, admitted on [DATE], for suicidal ideation. She was placed on an administrative involuntary hold by a physician on 8/12/20, based on being a danger to herself. DE evaluations, conducted on 8/13/21 and 8/14/21, concluded Patient #4 was still at risk of self-injury, and her involuntary hold was extended. A DE evaluation, conducted on 8/18/20, concluded Patient #4 was no longer likely to injure herself. She was released from an involuntary hold at that time and discharged on [DATE].

A nursing note for Patient #4, dated 8/15/20 at 9:21 PM, stated "Pt requested a sleeping med. Give Trazadone 75 mg po. Explained dosing to pt at which time she suddenly stated 'I have a terrible reaction to Trazadone, I'm going to make myslef [sic] throw up' Pt went into bathroom made herself throw up."

A provider note for Patient #4, dated 8/16/20 at 12:21 PM, stated "I am aware of patient making herself vomit after taking trazodone."

An undated, hand-written note, signed by Patient #4, stated, "Please do not give me ANY new drug without telling me you are doing so. I have 40-50 different drugs cause what happened over the past 5 days. Trazadone is a No No!"

The Director of the BHU was interviewed on 4/29/21 beginning at 9:30 AM. She reviewed Patient #4's record and confirmed it appeared nursing staff gave the medication prior to informing her what she was giving.

There was no documentation Patient #4 was informed of the new medication, including benefits and risks, prior to administration of the medication, to allow for informed consent.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**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 a nursing care plan (as a part of an interdisciplinary treatment plan) was followed for 1 of 7 patients (Patient #4) whose records were partially reviewed. This resulted in a failure to educate on medications. Findings include:

Patient #4 was a [AGE] year old female, admitted on [DATE], for suicidal ideation. She was placed on an administrative involuntary hold by a physician on 8/12/20, based on being a danger to herself. DE evaluations, conducted on 8/13/21 and 8/14/21, concluded Patient #4 was still at risk of self-injury, and her involuntary hold was extended. A DE evaluation, conducted on 8/18/20, concluded Patient #4 was no longer likely to injure herself and she had the capacity to make informed decisions about treatment. She was released from an involuntary hold at that time and discharged on [DATE].

A policy, "Adult Behavioral Health Unit: Plan of Care-Operational Structure and Scope of Work," dated 9/16/20, stated "The RN provides education to patients on health issues including but not limited to medication, diagnosis and coping skills."

Patient #4's interdisciplinary "Treatment Plan," included the following nursing interventions:

- "Nursing staff will provide medication education individually, during groups, and with the use of written handouts. Patient will be encouraged to verbalize understanding of medication information and the importance of consistent medication compliance daily until they discharge."

- "Patient will be presented with medication education materials regarding common, severe, and rare side effects associated with their prescribed medications. This information will be reinforced and discussed as needed throughout the patient's stay."

-- "Patient will obtain education related to using medication effectively, including exploration of the role of medication in managing symptoms of depression, as well as potential benefits and side effects."

- "Patient will be provided with medication education and will be encouraged to make an informed decision about their medications."

Although multiple prescribed medications were being administered to Patient #4, there was no documentation that nursing staff educated her regarding her medications during her stay, until the day she discharged , at which time, a nursing note, dated 8/19/20 at 2:19 PM, included "pt medication education."

A nursing note, dated 8/15/20 at 10:21 PM stated Patient #4 "requested a sleeping med. Give Trazadone 75 mg Po. Explained dosing to pt at which time she suddenly stated 'I have a terrible reaction to Trazadone, I'm going to make myslef [sic] throw up.' Pt went into bathroom made herself throw up."

A grievance letter from Patient #4 to Patient Advocacy related to her hospitalization on [DATE] through 8/19/20, stated "The nurse handed me the pills, I swallowed them and then she told me. When I heard it was trazadone I just flipped."

The Director of BHU was interviewed on 4/29/21 at 9:30 AM. She stated medication education usually started with the provider. However nursing staff was expected to ask patients if they had any questions prior to administration of a new medication. She stated side effects were often discussed during groups. She confirmed Patient #4's record did not include documentation Patient #4 was educated related to medications, including the trazadone, which was a new medication administered to Patient #4 before educating her.

Patient #4's nursing care plan was not followed as it related to medication education.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, grievance documentation review, and staff interview, it was determined the hospital failed to ensure licensed nurses who provided services adhered to hospital policies and procedures for 1 of 7 patients (Patient #4) whose records were reviewed. This resulted in incomplete pain assessment, failure to complete an Event Notification report, failure to complete Adverse Event documentation, and failure to update medication list adverse effects. Findings include:

Patient #4 was a [AGE] year old female, admitted on [DATE], for suicidal ideation. She was placed on an administrative involuntary hold by a physician on 8/12/20, based on being a danger to herself. DE evaluations, conducted on 8/13/21 and 8/14/21, concluded Patient #4 was still at risk of self-injury, and her involuntary hold was extended. A DE evaluation, conducted on 8/18/20, concluded Patient #4 was no longer likely to injure herself and she had the capacity to make informed decisions about treatment. She was released from an involuntary hold at that time and discharged on [DATE].

1. The hospital's policy, "Pain Management," dated 3/12/21, included the following information:

"A comprehensive pain assessment will be conducted & documented in the pain assessment screen by the RN on admission to the hospital, following changes in level of care, following invasive procedures and with the onset of new pain." The comprehensive pain assessment includes but is not limited to, "...Any pain relief methods that have proven effective ... The patient's pre-hospitalization history of pain, analgesic use, response to pain therapy, medication tolerance & history of substance abuse." Under the section "Ongoing Assessment," it stated, "Patients must be assessed before and after every PRN pain medication is given...."

There was no documentation Patient #4 was asked what pain relief methods had proven effective in the past, her pre-hospitalization history of pain, analgesic use, response to pain therapy, medication tolerance, or history of substance abuse, except that Patient #4 reported use of THC to help her sleep.

A nursing note, dated 8/15/20 at 5:23 PM, documented Patient #4 reported a headache rated as a 10 on a scale of 0-10, and she was treated with "Distraction, Medication, Rest, Hydration/Encourage Fluids." There was no documented post-assessment of her pain until the next day on 8/16/20 at 8:55 AM.

The Director of BHU was interviewed on 4/29/21 at 9:30 AM. She stated nurses generally asked patients what had worked well in the past and documented answers in nursing notes. She stated nurses reassess pain "usually within 30 minutes" after administration of pain medications. She reviewed Patient #4's record and was unable to point out necessary documentation related to assessment and re-assessment of pain.

The hospital's policy related to nursing assessment of pain for Patient #4 was not followed.

2. The hospital's "Event Notification Report Policy,"dated 8/16/19, included the following information:

- "All employees are expected to participate in the detection and reporting of any event that is out of the ordinary of routine care, including errors, medication error, near miss, hazardous/unsafe condition, process failures, injuries involving patients, visitors and staff."

- "Within a culture of safety, there is continuous reporting of patient safety events, near misses and hazardous conditions so these occurrences can be analyzed and processes can be changed or systems improved to reduce risk and prevent patient harm."

- "Event is any happening that is not consistent with the routine care of a particular patient whether or not it resulted in harm..."

A nursing note for Patient #4, dated 8/15/20 at 9:21 PM, stated "Pt requested a sleeping med. Give Trazadone 75 mg po. Explained dosing to pt at which time she suddenly stated "I have a terrible reaction to Trazadone, I'm going to make myslef [sic] throw up." Pt went into bathroom made herself throw up."

The above described event was not consistent with the routine care of a patient and qualified for Event Notification.

The Director of BHU was interviewed on 4/29/21 at 10:20 AM. She confirmed there was no Event Notification report filed or other type of incident report for Patient #4.

Nursing staff did not follow hospital policy on Event Notification as it related to Patient #4.

3. The hospital's policy, "Adverse Drug Reactions," dated 10/29/20, included the following information:

- "Adverse drug reactions are defined as any responses which are noxious, unintended, or unexpected and which occur..."

- "The Pharmacy Department will be notified of any patient thought to have experienced an adverse drug effect..."

- "...Any reaction that is questionable should be reported for further evaluation."

A nurse shift summary, dated 8/15/20 at 1:39 PM: "Pt ...upset that she has a headache and stomach ache/nausea, she blames this on taking generic levothyroxine this AM,..." Nursing notes documented Patient #4's pain in the 8-10 range for 3 days following administration of generic levothyroxine (rather than brand name Synthroid).

The Director of BHU was interviewed on 4/29/21 at 10:20 AM. She confirmed there was no Adverse Event report filed or other type of incident report for Patient #4.

Nursing staff did not follow hospital policy related to completing an Adverse Drug Reaction form on Patient #4's potential reaction to the generic form of Synthroid.

4. A policy, "Obtaining and Maintaining the Patient Allergy List," dated 5/19/16, stated "When additional allergy information becomes available...this allergy information will be reconciled with the allergy information currently in the medical record (EMR) and the list will be updated."

An undated, hand-written note, signed by Patient #4, stated, "Please do not give me ANY new drug without telling me you are doing so. I have 40-50 different drugs cause what happened over the past 5 days [referencing severe headache]. Trazadone is a No No!"

There was no documentation Patient #4 was asked about the drug intolerance's she referred to in her note, to ensure her medical record included all of her drug allergies and intolerance's.

The above referenced reactions/potential reactions related to Synthroid and Trazadone were not updated on her Patient Allergy List as adverse reactions to alert staff.

The Director of the BHU was interviewed on 4/29/21 at 9:30 AM. She stated that when a nurse became aware of a reaction to a medication, she was to update the list of allergies/adverse reactions in the medical record. She reviewed Patient #4's record and confirmed her allergy/adverse reaction list was not updated during her hospitalization , beyond "bee pollen" upon arrival to the hospital.

Patient #4's nurses failed to follow hospital policy regarding the update of allergy information in the patient record.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, document review, CDC infection control guideline review, and staff interview, it was determined the hospital failed to employ adequate infection control measures to prevent the spread of COVID-19 for staff members entering the hospital. This had the potential for increased risk of COVID-19 exposure for all patients and staff. Findings include:

CDC infection control guidelines for COVID-19, dated 2/10/21, stated, "Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection..." This guideline was not followed.

A hospital policy for COVID-19 employee screening was requested. None was provided. A document, titled, "WELLSCREEN USER GUIDE" was provided. The document stated, "Kootenai Health is installing eight freestanding WellScreen kiosks that employees will be expected to use prior to beginning their work." It stated this was effective 2/10/21 for the hospital campus. The document stated the kiosks would take the employee's temperature and the employee would answer a short series of questions about symptoms of illness. If the employee had a temperature, or answered yes to any of the symptom questions, the employee would not be able to report to work until symptoms resolved or they were cleared by Employee Health.

The "WELLSCREEN USER GUIDE" included a section of frequently asked questions and answers, including:

"Are these mandatory? Employees working in locations with screening kiosks are expected to use them."

"How will leaders know if their employees are using a kiosk? Leaders will have access to a WellScreen dashboard. The dashboard will allow them to view system utilization."

A WellScreen kiosk was located inside the entrance to the Administration building. On 4/29/21 at 8:05 AM, 2 employees were observed to walk past the kiosk, clock in on the time clock, and continue into the building without using the kiosk.

The Executive Director of Quality and Infection Prevention was interviewed on 4/28/21 at 11:00 AM. She provided a tour of a hospital entrance and a demonstration of a WellScreen kiosk. When asked how employee compliance was assessed, she stated the hospital received daily reports of the number of employees using the kiosks each day. The reports were sent to department managers and it was the managers' responsibility to compare the report to the staff assigned to work that day. The Executive Director of Quality and Infection Prevention confirmed the managers were not required to report the compliance of employees in their departments. She stated staff were stationed at the kiosks for the first week to assist and answer questions about the kiosks, however, no surveillance had been completed since the first week, to determine staff compliance with screening.

The BHU Director was interviewed on 4/29/21 at 9:25 AM. She stated employees were expected to use the kiosks if one was available, and stated they were not available at all locations. The BHU Director stated she had not seen a report on WellScreen use for her employees. She stated employees on the BHU unit were not using the WellScreen kiosks and they were expected to take their temperatures when they reported to work. She stated there was no documentation of employee screening for COVID-19 symptoms or exposure for staff on BHU.

The Director of Clinical Services over 3 medical/surgical floors was interviewed on 4/29/21 at 2:15 PM. He stated the managers received daily emails that included the names of employees who used the WellScreen kiosk the previous day. He stated he received the emails for the nephrology floor as he was the acting manager. The Director of Clinical Services stated on weekdays he compared the list to the number of employees scheduled to work on that day and estimated approximately 75% compliance. He stated he did not report that information to the Infection Prevention department as he had not been directed to do so.

The hospital failed to ensure all employees were screened for symptoms of or exposure to COVID-19 prior to reporting to work, to prevent the transmission of COVID-19 to patients and other employees.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies, record review, and staff interview, it was determined the hospital failed to follow their policy to identify at an early stage of hospitalization patients who were likely to suffer adverse health consequences upon discharge. This lack of screening directly affected 1 of 7 patients (Patient #2) whose records were reviewed for discharge planning and who were discharged home. Findings include:

The BHU's policy, "Kootenai Behavioral Health Transition of Care (Discharge Planning,)" approved 4/23/21, stated, "The transition process begins at the time of admission to the inpatient units. Information is gathered from the patient, providers, parents, and legal guardian if applicable to assess current services and evaluate the potential need for additional services upon transition to the next level of care."

During an interview on 4/29/21 beginning at 9:30 AM, the Case Management Supervisor explained the discharge planning procedure. She stated Case Managers were responsible for discharge planning and documented the discharge plans in the patients' records. The Case Management Supervisor stated each patient was assigned a Case Manager at admission. When asked if discharge planning differed for patients with frequent admissions, she stated the Case Manager would contact the outside provider the patient was referred to upon previous discharge to determine if the patient accessed services after discharge from the hospital as instructed.

Patient #2 was a [AGE] year old male admitted on [DATE], with a primary diagnosis of schizophrenia, paranoid type. He was discharged from the hospital on [DATE].

Patient #2's record included a psychiatric evaluation, dated 4/18/21, signed by a psychiatrist. It stated, "The patient is a [AGE]-year-old single Caucasian male with a history of multiple psychiatric hospitalization s, and was just discharged from his last one 2 weeks ago."

Patient #2's record included a "Case Management Adm [admission] Assessment, signed by the Case Management Supervisor. It included "Discharge High Risk Factors: Chemical Dependence, Medications, Mental Health Issues, Safety," and "Do They Have a Current Care Provider? No." It also stated, "Anticipated Needs at Discharge Summary: Other Physician/Agency, Therapist/Agency, Pt [patient] will be referred for CD [chemical dependency] treatment and therapy upon stabilization." The assessment did not document communication with an outside provider to determine if Patient #2 had accessed care since his previous discharge 2 weeks earlier. It did not include a specific plan to meet his needs after discharge from his current hospitalization .

During an interview on 4/29/21 at 1:00 PM, the Case Management Supervisor confirmed Patient #2's Case Management admission assessment did not include communication with the outside provider to determine if he had accessed services between his prior discharge and his current admission. She confirmed there was no documentation of discharge planning prior to the day of Patient #2's discharge.

The hospital failed to ensure Patient #2's discharge planning needs were identified and addressed.
VIOLATION: DISCHARGE PLANNING - PT RE-EVALUATION Tag No: A0802
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies, record review, and staff interview, it was determined the hospital failed to ensure discharge plans were re-evaluated to identify changes that required modification of the discharge plan. This lack of re-evaluation directly affected 1 of 7 patients (Patient #2) whose records were reviewed for discharge planning and who were discharged home. Findings include:

The BHU's policy, "Kootenai Behavioral Health Transition of Care (Discharge Planning,)" approved 4/23/21, stated, "The interdisciplinary treatment team...reviews the transition plan (discharge plan) to assess current needs and additional resources recommended or available to the patient. Every effort is made to work with the patient, and family/legal guardian if applicable, to have documented aftercare appointments within seven days of transition...The care manager/discharge planner will record transition planning efforts in the electronic medical record."

Patient #2 was a [AGE] year old male admitted on [DATE], with a primary diagnosis of schizophrenia, paranoid type. He was discharged from the hospital on [DATE].

Patient #2's record included "CONTACT INFORMATION" that stated "none" for next of kin. The line for "PERSON TO NOTIFY" was blank. His record stated he was hospitalized on an involuntary basis as it was determined he was a danger to himself.

Patient #2's record included a "Case Management Adm [admission] Assessment, signed by the Case Management Supervisor. It included "Discharge High Risk Factors: Chemical Dependence, Medications, Mental Health Issues, Safety," and "Do They Have a Current Care Provider? No." It also stated, "Anticipated Needs at Discharge Summary: Other Physician/Agency, Therapist/Agency, Pt [patient] will be referred for CD [chemical dependency] treatment and therapy upon stabilization."

Patient #2's record did not include documentation of discharge planning during his 6 day hospitalization . A note, dated 4/23/21 at 11:31 AM, signed by a Case Manager, stated Patient #2 had a court hearing and his involuntary status was discontinued. A note, dated 4/23/21 at 1:27 PM, stated Patient #2 would resume ACT (Assertive Community Treatment) as an outpatient after discharge.

Patient #2's record included discharge instructions, given to him at the time of discharge. The instructions stated, "ACT TEAM...Appointment: Resume all services at discharge, [Name] will be reaching out to you today."

Patient #2's record included a nursing note, dated 4/23/21 at 2:51 PM. It stated he appeared to have increasing paranoia, and "He stated that he is waiting to get a hold of a friend for a ride and place to stay and doesn't have a cell phone here."

Patient #2's record included a nursing note, dated 4/23/21 at 6:43 PM. It stated he was discharged at 6:35 PM. The note stated Patient #2 said he did not want to take a taxi as someone had stolen his apartment key and he would be unable to get into his apartment. The note also documented a call from the crisis center staff saying that Patient #2 went to the crisis center after discharge from the hospital and said he needed a place to stay.

Patient #2's record included a nursing note, dated 4/24/21 at 3:28 PM. It stated the nurse received a phone call from a hospital ED located 44 miles away, stating Patient #2 was in their ED.

During an interview on 4/29/21 at 1:00 PM, the Case Management Supervisor confirmed there was no documentation of discharge planning prior to the day of Patient #2's discharge. She stated she expected Patient #2's involuntary status to be continued at his court hearing and did not think he would be discharged . The Case Management Supervisor stated she called the ACT team on 4/23/21 to set up an appointment for Patient #2 but was unable to reach them. She left a message for them to call Patient #2 after his hospital discharge to set up services. She stated she did not know Patient #2 did not have a phone. The Case Management Supervisor confirmed the ACT team would not have been able to contact Patient #2 as he did not have his phone or keys to his apartment. She stated the nurse who documented the information about his phone and keys should have contacted the Case Manager or the ACT team with that information.

The hospital failed to ensure Patient #2's discharge plan was re-evaluated to identify and address all risks.