HospitalInspections.org

Based on staff interview and review of medical records, bylaws and medical staff rules, it was determined the CAH's governing body failed to ensure they assumed responsibility for determining, implementing, and monitoring policies governing the CAH's medical staff and medical care. This directly affected the care of 4 of 10 inpatients (#3, #7, #28, and #29), whose records were reviewed, and had the potential to affect all patients. The lack of oversight had the potential to prevent patients from receiving appropriate assessment and treatment by physicians and RNs. Findings include:

1. The governing body had not defined the responsibilities of the medical staff in relation to mid-level providers. Examples of the lack of physician involvement include:

a. Patient #7's medical record documented a 24 day old male infant who was admitted to the CAH on 6/17/13 for a fever. Laboratory and radiology tests confirmed he had a urinary tract infection and patchy infiltrates in his lungs. He was discharged home on 6/19/13.

Patient #7's "HISTORY AND PHYSICAL," signed on 6/22/13, and a "DISCHARGE FROM OBSERVATION/HISTORY AND PHYSICAL," dictated 7/02/13, were written by an NP. A "PROGRESS NOTE," dated 6/17/13 but not timed was written by an NP. Another "PROGRESS NOTE," dated 6/18/13 at 9:00 AM, was written by a PA. The discharge summary, dated 6/19/13, was written by a PA. All orders were written by mid-level providers. No physician documentation was present in the medical record.

The Chief of Staff, a physician, was interviewed on 7/24/13 beginning at 10:05 AM. He stated Patient #7 was seen by an NP in the hospital clinic prior to admission. He stated he saw the patient at some point during his stay but said this was not documented.

b. Patient #3's medical record documented a 78 year old female who was admitted to the CAH on 5/01/13. She died on 5/13/13. Her diagnoses included pancreatic cancer and diabetes.

Patient #3's "HISTORY AND PHYSICAL," dated 5/01/13, was conducted by a PA. A physician who provided some weekend coverage for the CAH wrote a progress note on Saturday 5/04/13 at 10:40 AM. The note stated the physician discussed laboratory results with Patient #3's spouse and the results were improving slowly. The next documentation by a physician was dated 5/11/13 when another weekend physician covered the hospital. The PA documented on 5/06/13 (not timed) that he spoke with Patient #3's spouse and then spoke with his supervising physician and it was decided to stop treatment and provide comfort measures only. This appeared to contradict the physician note from 5/04/13 that implied Patient #3's condition was improving. Except for 5/04/13, no documentation was present that Patient #3 had been examined by a physician from her admission on 5/01/13 until 5/11/13.

The documentation in Patient #3's record was confirmed by the DON on 7/23/13 beginning at 2:05 PM.

c. "Medical Staff Rules," part of the medical staff bylaws, were dated 6/27/12. The rules stated "All patients at Teton Valley Hospital and Surgicenter are under the care of a physician...A physician may turn direct care of any of his patients over to either a midlevel practitioner...The physician remains responsible for supervision of the midlevel practitioner to whom he has delegated patient care." The rules did not define what under the care of a physician meant. The rules did not delineate the responsibilities of the physician to demonstrate that patients were under his care. The rules did not state that a physician had to examine patients or have any contact with them. The rules did not state how physician involvement should be documented.

The Chief of Staff was interviewed on 7/24/13 beginning at 10:05 AM. He stated physicians made rounds on patients but he also said this was not documented. He stated the roles of physicians and mid-levels was "...pretty nebulous and not well defined."

The CEO was interviewed on 7/26/13 beginning at 8:45 am. He stated hospital bylaws required patients to be under the care of a physician. He also confirmed the governing body had not developed mechanisms to enforce the bylaws.

The CAH did not develop policies which described practices physicians must comply with in order to demonstrate CAH patients were under the care of a physician.

2. The governing body failed to develop policies defining the CAH's wound care team. Examples include:

a. Patient #28's medical record documented a 66 year old female who was admitted to the CAH on 7/23/13. She was currently a patient as of 7/26/13. Her "EMERGENCY ROOM REPORT," dated 7/23/13, diagnosed cellulitis of her lower legs and a urinary tract infection. The report stated Patient #28 was diabetic and had chronic left foot ulcers.

"PHYSICIANS ORDERS," written by an NP and dated 7/23/13 at 1:48 PM, called for a "Wound Consult" for Patient #28.

Patient #28's medical record was reviewed on 7/25/13 at 9:10 AM. It was noted that "Assessment and Progress Notes," written by an LPN at 2:15 PM, 4:50 PM, and 5:30 PM on 7/23/13, described Patient #28's skin condition, left foot wound, and reddened areas on her body. A progress note stating it was a wound care consult which included an evaluation was not documented.

An entry on the "PHYSICIANS ORDERS" form, written by the same LPN noted above and dated 7/23/13 but not timed, stated "Wound care Consult L foot." The complete entry stated "1) Clean wounds with [normal saline], measure wounds. 2) Apply skin barrier to around wounds. 3) Apply Normagel to wounds. 4) Cover with Mepilex border." The wound care "ORDERS" were signed "[name] LPN/Wound Care Team." The "ORDERS" were not cosigned by a physician or mid-level provider.

An "Assessment and Progress Notes," written by an RN at 11:15 AM on 7/24/13, documented the above wound care orders were followed.

The DON was interviewed on 7/25/13 beginning at 9:40 AM. She reviewed the record and confirmed the above documentation. She stated the CAH had a wound care team consisting of 2 RNs and 2 LPNs. She stated the team evaluated patients with wounds and wrote orders for treatment. She stated the medical staff deferred to the team regarding the treatment of wounds. She was asked for a copy of the policy that defined the wound care team and its role. She stated a policy describing the wound care team had not been developed.

b. Patient #29's medical record documented an 80 year old female who was admitted to the CAH on 7/11/13. She was discharged on 7/15/13. Her admitting diagnoses included diabetes, decubitus ulcers on her buttocks and skin lesions on her arms and trunk.

Patient #29's medical record was reviewed on the morning of 7/25/13. Patient #29's admitting orders, dated 7/11/13 at 7:34 AM, called for a "wound care consult." A formal note identifying it as a wound consult was not documented. An order, written by an LPN and dated 7/12/13 but not timed, called for treating the skin lesions with Tegaderm and Aquaphor cream. The order stated Patient #29 had a "...1 cm round hole with Deep Eschar in the center to the [right] of the umbilicus." The order called for the wound to be irrigated with normal saline and covered with a "Mesalt" dressing. The order also directed specific treatment of the 2 decubitus ulcers. The order was written by an LPN from the "Wound Care Team." It was not cosigned by a physician or mid-level practitioner.

The DON was interviewed on 7/25/13 beginning at 4:20 PM. She reviewed the record and confirmed the above documentation. She stated the LPN did not have privileges to write orders and confirmed the orders had not been cosigned by a qualified practitioner.

The CEO was interviewed on 7/26/13 beginning at 8:45 AM. He confirmed LPNs did not have privileges to write orders for wound care. He stated he was not aware if the governing body had discussed the wound care team or its role since he became the CEO, approximately 1 year ago.

The governing body did not define the role of the wound care team.

Based on staff interview, observation of patient care, and review of hospital policies, it was determined the facility failed to ensure the implementation of procedures to avoid potential transmission of infections and communicable diseases. This directly impacted 1 of 1 isolation patient (#28) whose care was observed and whose record was reviewed. The lack of direction to staff had the potential to impact all staff and patients in the facility. Failure to follow policies and standard precautions had the potential to allow for transmission of infections. Findings include:

1. Patient #28's medical record documented a 66 year old female who was admitted to the CAH on 7/23/13. She was currently a patient as of 7/26/13. Her "EMERGENCY ROOM REPORT," dated 7/23/13, diagnosed cellulitis of her lower legs and a urinary tract infection. The report stated Patient #28 was diabetic and had chronic left foot ulcers.

"PHYSICIAN'S ORDERS," dated 7/24/13 at 7:50 AM, stated to culture Patient #28's left foot ulcer and implement "Strict Contact Precautions."

The LPN caring for Patient #28 was interviewed at 9:15 AM on 7/25/15. She stated she was not aware the patient had orders for contact precautions. She stated she did not know specifically what the term contact precautions meant at the hospital.

Patient #28 was observed at 9:40 AM on 7/25/15 with the DON. No special precautions were observed that had been implemented. The surveyor asked the DON how the hospital defined "Strict Contact Precautions." The DON called the nurse who had noted the order for contact precautions. The DON stated the nurse said she had missed the order and had not implemented contact precautions. The DON also stated the hospital had not developed policies defining contact precautions or other types of isolation.

The CAH had not developed policies to guide staff to implement isolation policies.



32213

2. On 7/23/13, beginning at 11:00 AM, preparation of food for lunch was observed in the hospital kitchen. During this time a kitchen staff member was observed wearing gloves and moving dirty dishes from a carrier to a sink to be sprayed. The staff member then stated she had to put away some clean dishes before she could wash the dirty dishes. While wearing the same gloves, she picked up several clean dishes and placed them on a rack in the dining area. The staff member then went to the food preparation area and wrapped a prepared dessert in plastic wrap and placed it in the refrigerator. The staff member then returned to the dish cleaning area and placed more dirty dishes in the sink to be sprayed. She sprayed the dirty dishes and placed them in a dishwasher. She then picked up a clean pot and some clean tools and placed them in the food preparation area. The staff member did not remove her gloves until she went into the office located outside the kitchen area to access information on the computer. She did not perform hand hygiene after removing gloves.

When the staff member returned to the food preparation area, she was observed to cough into her hands and then don clean gloves. The staff member then returned to the food preparation area and assisted another staff member with food preparation. The staff member did not perform hand hygiene after coughing into her hands and before donning a new pair of gloves.

At approximately 11:55 AM, the staff member removed her gloves and stated she was leaving to go to the restroom. She returned to the kitchen at 11:57 AM and donned new gloves. The staff member did not perform hand hygiene upon her return to the kitchen from the restroom and before donning gloves.

The "Hand Hygiene Policy and Procedure," approved 4/23/12, stated indications for hand hygiene include before donning gloves and after removing gloves, after using the restroom, and before coming on duty.

The Infection Control Officer was interviewed on 7/24/13 at 1:30 PM. She stated the "Hand Hygiene Policy and Procedure" applied to all hospital staff. She confirmed the kitchen staff member had not adhered to the facility policy. She also confirmed that the staff member handling dirty dishes and then handling clean dishes without changing gloves had the potential to allow for the transmittal of communicable disease.

Staff did not follow the established hand hygiene policy.

Based on staff interview and review of medical records and policies, it was determined the CAH failed to ensure an RN evaluated and monitored the nursing care of each patient. This directly affected the care of 4 of 10 inpatients (#2, #3, #11, and #29) whose records were reviewed and had the potential to affect the care of all inpatients. The lack of RN involvement had the potential to allow patients' conditions to deteriorate without intervention. Findings include:

1. The policy "Supervision and Evaluation of Nursing Care of Each Patient," dated 12/08/12, stated " There will be an RN assigned as charge nurse/supervisor on all shifts." The policy stated an RN would supervise all nursing personnel. The policy did not specify how RNs would evaluate patients in order to assign and monitor nursing care or how this evaluation would be documented.

The DON was interviewed on 7/25/13 beginning at 4:20 PM. She stated a policy that specified the RN's role in evaluating patients and monitoring nursing care had not been developed.

2. Patient #3's medical record documented a 78 year old female who was admitted to CAH swing bed status on 5/01/13. She died on 5/13/13. Her diagnoses included pancreatic cancer and diabetes.

Patient #3's nursing "Assessment and Progress Notes" documented she was assessed by an RN on the night shift beginning at 8:00 PM on 5/01/13. An RN documented that a care conference was held with Patient #3's family on 5/06/13 at 11:00 AM. Patient #3 was placed on comfort care measures at that time and curative efforts were abandoned. An assessment of the patient by an RN was not documented on 5/06/13. The first assessment of Patient #3 by an RN following the initial night shift occurred on the morning of 5/07/13. No other assessments of Patient #3 by an RN were documented through the time of her death at 9:05 AM on 5/13/13. Except for the RN assessments noted above, all nursing assessments were documented by an LPN.

The DON was interviewed on 7/23/13 beginning at 2:05 PM. She confirmed the lack of RN involvement in the care of Patient #3. She stated the CAH was often staffed with 1 RN to be in charge and cover the ED. She stated RNs performed initial patient assessments and LPNs provided routine patient care. She stated patients may be hospitalized for several days without assessment by an RN.

An RN did not evaluate Patient #3's nursing care.

3. Patient #29's medical record documented an 80 year old female who was admitted to the CAH on 7/11/13. She was discharged on 7/15/13. Her admitting diagnoses included diabetes, decubitus ulcers on her buttocks and skin lesions on her arms and trunk.

Patient #29's medical record documented an RN admitted her on 7/11/13 at approximately 10:30 AM and cared for her until 6:37 PM. No other documentation that an RN had assessed Patient #29 was present in her medical record through her discharge at 1:55 PM on 7/15/13. All "Assessment and Progress Notes" in Patient #29's record were written by an LPN.

The DON was interviewed on 7/25/13 beginning at 4:20 PM. She confirmed documentation of RN evaluation and oversight was not present in Patient #29's medical record.

An RN did not evaluate Patient #29's nursing care.



32213

4. Patient #11 was an 81 year old male admitted to the hospital on 6/17/13 for a pain pump implantation. He was discharged from the hospital on 6/18/13.

An LPN documented in "Assessment and Progress Notes" that Patient #11 was admitted to the nursing floor on 6/17/13 at 11:35 AM. She documented her assessment of Patient #11 at 12:30 PM. At 7:10 PM, the LPN documented in the "Vital Detail Report" that Patient #11 had an oxygen saturation, or 02 sat, of 87%. It was unclear if this reading was taken while Patient #11 was on oxygen or on room air. There was no documentation to indicate an RN had been notified of the low 02 sat or had performed an assessment of Patient #11 in relation to the low 02 sat.

According to "...Morphine Pump Trial Orders," signed by the physician on 6/17/13, if Patient #11's oxygen saturation fell below 89%, nursing staff were to administer Narcan, a drug that reverses the effects of some narcotic pain medications, and call the physician. There was no documentation in the medical record that Narcan had been given or that the physician had been called. There were no other vital signs recorded until 6:43 AM on 6/18/13, at which time Patient #11's 02 sat was 94% on 2 liters of oxygen.

The night shift LPN documented his assessment of Patient #11 at 9:30 PM. There was no documentation of Patient #11's oxygen saturation except "INTERVENTIONS: Check 02 Sat, Cardiac Monitor." There was no documentation in the medical record to indicate an RN had performed an assessment of Patient #11.

The day shift LPN documented her assessment of Patient #11 at 7:40 AM on 6/18/13 and continued to care for Patient #11 until his discharge from the hospital at 10:45 AM on 6/18/13. There was no documentation in the medical record to indicate an RN had performed an assessment of Patient #11 prior to his discharge.

The DON reviewed the record and was interviewed on 7/25/143 at 11:00. She stated it is the practice of the hospital for the RN to assess each patient upon admission to the nursing floor. She confirmed there was no documentation to indicate an RN had performed an assessment of Patient #11 upon admission. She confirmed that the RN should have been notified of an oxygen saturation of 87% and Patient #11 should have been assessed by the RN at that time. The DON confirmed an RN had not overseen the care of Patient #11.

Patient #11's care was not supervised and evaluated by an RN.

5. Patient #2 was a 52 year old male admitted to the hospital on 4/25/13 for a partial amputation and incision and drainage of four fingers on his left hand. He was discharged from the hospital on 4/26/13.

An LPN documented in "Assessment and Progress Notes" that Patient #2 was admitted to the nursing floor at 5:20 PM on 4/25/13. The LPN also documented her assessment of Patient #2 at 5:20 PM. The LPN documented that she gave report to the oncoming shift, another LPN, at 7:00 PM. The night shift LPN documented his assessment at 7:15 PM. There was no documentation in the medical record to indicate an RN had performed an assessment of Patient #2.

At 7:25 AM on 4/26/13, an LPN documented her assessment of Patient #2 and continued his care during his time on the nursing floor until his discharge at 12:36 PM on 4/26/13. There was no documentation in the medical record to indicate an RN had overseen the care of Patient #2.

The DON reviewed the record and was interviewed at 11:00 on 7/25/13. She stated it is the practice of the hospital for the RN to assess each patient upon admission to the nursing floor. She confirmed there was no documentation to indicate an RN had performed an assessment of Patient #2 upon admission. The DON also confirmed there was no documentation to indicate an RN oversaw the care of Patient #2.

Patient #2's care was not supervised or evaluated by an RN.

Based on staff interview and review of medical records and policies, the hospital failed to ensure documentation was complete and/or accurate for 6 of 29 patients (#4, #7, #13, #11, #23, and #24) whose records were reviewed. This resulted in incomplete or inaccurate medical records. It had the potential to interfere with clarity of information related to the course of treatment and completeness of the medical record. Findings include:

1. Patient #11 was an 81 year old male admitted to the hospital on 6/17/13 for a pain pump implant. He was discharged from the hospital on 6/18/13. His medical record was incomplete as follows:

a. His medical record contained a form titled "Pre-op Orders." The form included admit orders, an order for a PT/INR, IV fluids of lactated ringers and an antibiotic. The orders were not signed, dated or timed by a physician. The RN signed off the orders at 8:25 AM on 6/17/13. A "PRE-PROCEDURE ASSESSMENT," completed by the RN on 6/17/13 at 3:31 PM, documented that the PT/INR had been collected and lactated ringers had been initiated at 8:03 AM. The RN also documented that the antibiotic had been sent to the OR with anesthesia at 8:37 AM.

"Medical Staff Rules," last approved by the hospital on 6/27/12, stated "All clinical entries in the patient's records shall be accurately dated and authenticated. Authentication means to establish authorship by written signature or identifiable initials." In addition, "Provider Orders - Time and Date Policy," last approved by the hospital 9/15/12, stated "All providers providing care of any patient...shall include the date and time when writing orders in any patient chart."

The DON reviewed the record and was interviewed on 7/25/13 beginning at 11:00 AM. She confirmed the pre-op orders lacked authentication.

b. A "PACU FORM," completed by the RN on 6/17/13 at 11:25 AM, documented that at 10:35 Patient #11 had complained of pain to his right upper abdomen. The RN documented she gave Patient #11 Dilaudid for his pain. There was no further documentation to indicate how much Dilaudid was given. Patient #11's "OMAR Summary," an electronic medication administration record, did not include any documentation that Dilaudid had been given during Patient #11's time at the hospital.

The "Charting of Medication Policy," approved by the hospital on 7/13/13, stated that "all medication given to patients...will be recorded on the electronic medical record..."

The DON reviewed the record and was interviewed on 7/25/13 beginning at 11:00 AM. She confirmed there was no documentation in the medical record to indicate Dilaudid had been given. She stated that all medications should be documented on the "OMAR Summary." She confirmed Patient #11's course of treatment was unclear related to the lack of complete documentation of medication administration.

c. Patient #11's medical record contained a "Medication Reconciliation Report" listing all the medications he was taking with a box next to each for the physician to mark continue or discontinue upon discharge. Patient #11's "Medication Reconciliation Report" contained three pages of medications, with a place for the physician to sign and date the orders at the bottom of each page. The physician signed the first page on 6/18/13. The remaining two pages were not signed by the physician, though they contained medication the physician had ordered to continue. An RN noted and signed each of the three pages on 6/18/13 at 4:00 PM.

The DON reviewed the record and was interviewed on 7/25/13 beginning at 11:00 AM. She confirmed that each page of the "Medication Reconciliation Report" was an order for the continuation or discontinuation of Patient #11's medications and should therefore be signed and dated by the physician.

Patient #11's medical record was incomplete.

2. Patient #4 was a 44 year old male admitted to the hospital on 10/02/12 for an incisional hernia repair. He was discharged 10/03/12.

Patient #4's medical record contained a "PATIENT CONTROLLED ANALGESIA (PCA) MONITORING" form. The form was used by nursing staff to document the type of medication Patient #4 was receiving in his PCA pump, the signatures of the RNs that programmed the pump, the amount of medication used by Patient #4 each shift, and teaching done by nursing staff related to the use of the PCA.

In the section "Pump Programming," there was a line for the signature of the RN that initiated the PCA pump, and a line labeled "2nd Signature" for the RN that checks the pump against the physician's orders. The RN had signed the first line. On the "2nd Signature" line, a second RN's name had been written on a clear blue sticky note and stuck over the signature line. The second RN had not actually authenticated the document as the second check of the physician's orders.

The DON reviewed the medical record and was interviewed on 7/25/13 beginning at 11:00 AM. She confirmed that a name written on a sticky note was not acceptable authentication.

Patient #4's "PATIENT CONTROLLED ANALGESIA (PCA) MONITORING" lacked authentication.



00023

3. Patient #23's medical record documented a 24 year old female who presented to the ED in active labor at 12:13 AM on 7/16/13. She delivered a baby girl at 12:55 AM on the same day.

A "VAGINAL DELIVERY RECORD," DATED 7/16/13 AT 2:43 AM, stated the physician delivered the baby. This was not accurate. The PA delivered the baby. Also, an "EMERGENCY ROOM REPORT," written by the PA and dated 7/16/13 at 10:49 AM, stated Patient #23 had mild vaginal tears which were evaluated by the physician. No documentation by the physician was present in the medical record.

The PA on duty in the ED at the time of the delivery was interviewed on 6/24/13 at 4:20 PM. He stated he was the provider that delivered the baby and the physician arrived after the delivery. He stated the physician did examine the mother. He stated the physician probably did not document the examination of the mother.

Patient #23's medical record was not accurate and did not include documentation by the physician who examined the patient after childbirth.

4. Patient #24's medical record documented a baby girl born on 7/16/13 at 12:55 AM to Patient #23. No documentation by the physician was present in the baby's record.

The PA on duty in the ED at the time was interviewed on 6/24/13 at 4:20 PM. He stated he was the provider that delivered the baby. He stated the physician arrived after the birth and examined Patient #24. He stated the physician probably did not document the examination of the mother.

Patient #24's medical record did not include documentation by the physician who examined the baby after birth.

5. Patient #13's medical record documented an 88 year old male who was admitted to the CAH on 6/10/13 and was discharged on 6/19/13.

Patient #13's medical record contained an extensive progress note written by a practitioner on 6/14/13 at 10:00 AM. The note was not signed to indicate who wrote it.

The DON reviewed the record on 7/24/13 beginning at 11:50 AM. She reviewed the progress note from 6/14/13 at 10:00 AM. She stated it was a practitioner's note but said she could not identify the author.

A progress note for Patient #13 was not signed to indicate who wrote it.

6. Patient #7's medical record documented a 24 day old male infant who was admitted to the CAH on 6/17/13 for a fever. He was discharged home on 6/19/13.

Patient #7's "HISTORY & PHYSICAL" was signed by the NP who dictated it on 6/22/13, 3 days after the patient was discharged. The date the "HISTORY & PHYSICAL" was dictated was not documented.

The Revenue Cycle Manager, who had administrative authority for medical records, was interviewed on 7/23/13 beginning at 9:15 AM. She stated she could not tell if the "HISTORY & PHYSICAL" was completed and available to staff before Patient #7 was discharged.

Patient #7's "HISTORY & PHYSICAL" did not document when it was written.