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Based on CAH policy review and staff interview, it was determined the CAH failed to develop policies that described all services furnished. This failure resulted in a lack of organizational clarity. Findings include:

The CAH policy table of contents was reviewed. It did not include policies describing occupational therapy, physical therapy, or speech language therapy services.

The CNO was interviewed on 4/05/18, beginning at 10:29 AM, and the CAH policy table of contents were reviewed in her presence. When asked if the CAH provided the services of occupational therapy, physical therapy, and speech language therapy, she stated yes. When asked if the CAH maintained polices which described the services of occupational therapy, physical therapy, and speech language therapy, the CNO stated she was unsure, but would investigate further.

The CNO was interviewed again on 4/05/18, beginning at 3:40 PM. She confirmed the CAH did not develop policies which described the services of occupational therapy, physical therapy, and speech language therapy.

The CAH did not have policies which described therapy services.

Based on medical record review, CAH policy review, and staff interview, it was determined the CAH failed to ensure an RN evaluated and provided supervision for 4 of 14 inpatients (#9, #10, #22, and #23) who received LPN nursing care and whose records were reviewed. This failure had the potential for inpatients' conditions to deteriorate without appropriate assessment and intervention by an RN. Findings include:

A CAH policy "Nursing Care of Each Patient Policy," approved 1/01/16, stated "All LPN's and CNA's will have an RN supervising the care given to patients at Teton Valley Hospital." This policy was not followed. Examples include:

1. Patient #23 was a 97 year old male who was admitted to the CAH on 10/05/17, with a diagnosis of dementia.

Patient #23's medical record included nursing care provided by an LPN on the following dates:

- 10/12/17
- 10/17/17

Documentation that Patient #23's LPN nursing care was evaluated by an RN was not present.

2. Patient #9 was an 80 year old female who was admitted to the CAH on 1/10/18, with a diagnosis of pneumonia.

Patient #9's medical record included nursing care provided by an LPN on the following dates:

- 1/10/18
- 1/13/18

Documentation that Patient #9's LPN nursing care was evaluated by an RN was not present.

3. Patient #10 was a 68 year old male who was admitted to the CAH on 11/28/17, for left knee surgery.

Patient #10's medical record included nursing care provided by an LPN on the following dates:

- 11/29/17
- 11/30/17

Documentation that Patient #10's LPN nursing care was evaluated by an RN was not present.

4. Patient #22 was a 51 year old male who was admitted to the CAH on 12/04/17, with a diagnosis of emergent hypertension.

Patient #22's medical record included nursing care provided by an LPN on the following date:

- 12/05/17

Documentation that Patient #22's LPN nursing care was evaluated by an RN was not present.

The CNO was interviewed on 4/05/18, beginning at 11:21 AM, and Patients #9, #10, #22, and #23 medical records were reviewed in her presence. She confirmed RN evaluation and supervision of LPN nursing care was not documented.

The CAH failed to ensure LPN nursing care was evaluated by an RN.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure medical records for 4 of 14 inpatients (#7, #11, #14, and #17) were complete and accurate. This resulted in a lack of reliable information to describe care provided by the CAH. Findings include:

1. The EMR contained documentation of practitioner orders for nursing tasks. These were not actually orders signed by the listed practitioner. The medical record was not accurate. Examples include:

a. Patient #11 was an 83 year old female who was admitted to the CAH on 1/05/18 and was transferred to another hospital on 1/10/18. Patient #11's medical record contained:

i. "Order measure intake and output ongoing written order by [the PA's name]." The order stated it was signed by a PA on 1/05/18 at 7:16 PM.

ii. Order vital signs ongoing VITALS Q 4 HOURS verbal with read back order by [the PA]." The order stated it was signed by a PA on 1/05/18 at 7:16 PM.

iii. "Order weight ongoing verbal with read back order by [the PA's name]." The order stated it was signed by a PA on 1/05/18 at 7:16 PM.

b. Patient #14 was a 60 year old female who was admitted to the CAH on 11/07/17 and was discharged on 11/10/17. Patient #14's medical record contained:

i. An order, dated 11/08/17 at 4:23 AM. The order stated, "Order custom nursing order every 24 hours Shower verbal with read back order by [physician name] scheduled Starting 11/08/17 at 04:23." The order was not signed by the physician named in the order.

ii. An order, dated 11/08/17 at 4:23 AM. The order stated, "Order custom nursing order every 12 hours Oral care verbal with read back order by [physician name] scheduled Starting 11/08/17 at 04:23." The order was not signed by the physician named in the order.

iii. An order, dated 11/08/17 at 4:23 AM. "Order custom nursing order ongoing up to chair verbal with read back order by [the physician]." The order was not signed by the physician named in the order.

c. Patient #17 was a 59 year old male who was admitted to the CAH on 12/03/17 and was discharged on 12/07/17. Patient #17's medical record contained:

i. An order, dated 12/03/17 at 9:07 PM. The order stated, "Order custom nursing order every 24 hours Shower verbal with read back order by [physician name] scheduled Starting 12/03/17 at 21:07." The order stated it was signed by the physician on 12/03/17 at 9:36 PM.

ii. An order, dated 12/03/17 at 9:07 PM. The order stated, "Order custom nursing order every 12 hours Oral care verbal with read back order by [physician name] scheduled Starting 12/03/17 at 21:07." The order stated it was signed by the physician on 12/03/17 at 9:36 PM.

iii. An order, dated 12/03/17 at 9:07 PM. The order stated, "Order custom nursing order Every hour while patient is awake Q1 HR round: Pain, Position, Personal Hygiene, Possessions verbal with read back order by [physician name] scheduled Starting 12/03/17 at 21:07." The order stated it was signed by the physician on 12/03/17 at 9:36 PM.

iv. A nursing order, dated 12/03/17 at 9:07 PM. The order stated, "Order peripheral IV care every 5 days verbal with read back order by [physician name]." The order stated it was signed by the physician on 12/03/17 at 9:36 PM.

The CNO was interviewed on 4/04/18 beginning at 9:05 AM. She reviewed the above orders. She stated, because of a problem with the EMR, the nurses were not able to enter nursing orders. She stated the work around was to enter nursing orders as physician orders. She stated these were not physician orders signed by a physician even though the EMR stated they were. She stated the documentation was not accurate.

Medical records contained documentation of practitioner orders that were not accurate.

2. Patient #11 was an 83 year old female who was admitted to the CAH on 1/05/18 and was transferred to another hospital on 1/10/18. Her diagnosis was CHF.

Patient #11's weight, on 1/09/18 at 9:00 AM, was 155 pounds. Her weight, on 1/10/18 at 9:10 AM, was 165 pounds. A Nursing Assessment, dated 1/10/18 at 6:40 PM, stated Patient #11's sodium level was critically low.

A progress note by the PA, dated 1/10/18 at 7:46 PM, stated Patient #11 was becoming more somnolent and her blood gas levels were deteriorating. It stated her sodium levels were not improving. It stated patient #11 was on oxygen. It stated the PA spoke with the cardiologist who recommended Patient #11 be transferred to an acute care hospital. Another progress note by the PA, dated 1/10/18 but not timed, stated Patient #11 would be transferred to the receiving hospital, which was approximately 1 hour and 21 minutes away, by private vehicle driven by the patient's son.

No documentation was present in the medical record that stated why Patient #11 was not being transported to the receiving hospital in an ambulance accompanied by trained medical personnel.

The CNO was interviewed on 4/05/18 beginning at 1:15 PM. She reviewed Patient #11's medical record. She stated the record did not document the rationale for the transfer of Patient #11 by private vehicle.

Patient #11's medical record was not complete.

3. Patient #7 was a 50 year old male who was seen in the CAH ED on 3/31/18, with a diagnosis of left pneumothorax and fractured ribs.

Patient #7's medical record included an "ED Provider Assessment," dated 3/31/18, signed by a physician. The assessment included a section titled "Allergies" which stated "Allergies not reviewed."

The CNO was interviewed on 4/05/18, beginning at 10:24 AM, and Patient #7's medical record was reviewed in her presence. She confirmed Patient #7's allergies were not reviewed. The CNO stated it was her expectation that patient allergies are reviewed and documented upon each new visit.

Patient #7's allergy documentation was incomplete.

Based on medical record and policy review and staff interview, it was determined the CAH failed to ensure properly executed consents and discharge summaries were documented for 6 of 14 inpatients (#9, #10, #11, #14, #22, and #26) whose records were reviewed. This failure resulted in a lack of clarity regarding whether patients were fully informed regarding their treatment and a lack of clarity regarding their course of treatment. Findings include:

1. Patient #9 was an 80 year old female who was admitted to the CAH on 1/10/18, with a diagnosis of pneumonia.

Patient #9's medical record included an inpatient admission consent. The consent was signed by Patient #9, but not dated. It could not be determined if Patient #9 was fully informed regarding her treatment prior to care being rendered.

The CNO was interviewed on 4/05/18, beginning at 11:37 AM, and Patient #9's medical record was reviewed in her presence. She confirmed Patient #9's consent was not properly executed.

Patient #9's consent was not properly executed.

2. Patient #10 was a 68 year old male who was admitted to the CAH on 11/28/17, for left knee surgery.

Patient #10's medical record included an "ANESTHESIA CONSENT." The consent was signed by Patient #10, but not dated. It could not be determined if Patient #10 was fully informed regarding his treatment prior to care being rendered.

The CNO was interviewed on 4/05/18, beginning at 11:21 AM, and Patient #10's medical record was reviewed in her presence. She confirmed Patient #10's consent was not properly executed.

Patient #10's consent was not properly executed.

3. Patient #26 was an 83 year old male who was admitted to the CAH on 4/02/18 after a fall.

Patient #26's medical record did not include a signed consent for treatment or documentation why it was not signed.

The CNO was interviewed on 4/05/18, beginning at 1:15 PM, and Patient #26's medical record was reviewed in her presence. She confirmed Patient #26's consent was not properly executed.

Patient #26's consent was not properly executed.

4. Discharge summaries were not defined or documented.

a. A policy that defined discharge summaries and what they should contain had not been developed.

The Revenue Cycle Director facilitated medical record review for surveyors during the survey. She was interviewed on 4/05/18 at 11:15 AM. She stated the CAH did not have a policy that addressed discharge summaries.

b. Patient records were missing discharge summaries. Examples include:

i. Patient #11's medical record contained a form labeled "Discharge Summary" dated 1/10/18 at 7:25 PM. The form included a section labeled "Hospital Course." Under this section was written, "None recorded." The section labeled, "Hospital Consults & Procedures" stated "None recorded," even though a consult by the PA with a cardiologist with privileges at the CAH was documented on 1/10/18.

ii. Patient #14 was a 60 year old female who was admitted to the CAH on 11/07/17 for total shoulder surgery. She was discharged on 11/10/17.

Patient #14's "Discharge Summary" was dated 11/10/17 but not timed. The form included a section labeled "Hospital Course." Under this section was written, "None recorded."

iii. Patient #10 was a 68 year old male who was admitted to the CAH on 11/28/17, for left knee surgery.

Patient #10's medical record included a "Discharge Summary" form, dated 11/30/17. The form included a section titled "Hospital Course" under which was documented "None recorded."

iv. Patient #22 was a 51 year old male who was admitted to the CAH on 12/04/17, with a diagnosis of emergent hypertension.

Patient #22's medical record included a "Discharge Summary" form, dated 12/05/17. The form included a section titled "Hospital Course" under which was documented "None recorded."

The CNO was interviewed on 4/05/18 beginning at 11:20 AM and again at 1:15 PM. She reviewed the above medical records. She confirmed the above documentation. She stated she thought the missing documentation was a problem with the EMR.

The CAH failed to ensure patient discharge summaries were complete.

Based on observation and staff interview, it was determined the CAH failed to ensure medical record information was safeguarded against destruction by water damage for 2 of 2 medical record storage areas observed. This failure had the potential to result in damage to medical records. Findings include:

A tour of the medical records storage area was conducted in the presence of the Maintenance Manager, Maintenance Engineer, and HIM Manager on 4/04/18, beginning at 9:56 AM. Two rooms were observed which stored original, non-archived medical records. The first room, located behind the IT Department, stored "older" original, non-archived medical records. The second room, located inside the Medical Records Department, stored "newer" original, non-archived medical records. The medical records were arranged in manila folders which were placed on exposed shelving. Fire suppression systems were noted in both rooms, however, there was no countermeasure to protect the exposed medical records from potential water damage.

The Maintenance Manager, Maintenance Engineer, and HIM Manager were interviewed together on 4/04/18, beginning at 10:06 AM. They confirmed the original, non-archived medical records were not protected from potential water damage.

The CAH failed to ensure medical records were safeguarded against destruction by water damage.

Based on medical record review and staff interview, it was determined the CAH failed to a ensure properly executed consent for release of medical information was performed for 1 of 3 swing bed patients (Patient #23), whose records were reviewed. This failure had the potential for patient medical information being inappropriately disclosed. Findings include:

Patient #23 was a 97 year old male who was admitted to the CAH on 10/05/17, with a diagnosis of dementia. He was admitted to swing bed status on 10/09/17, and discharged home on 10/17/17.

Patient #23's medical record included documentation by several RNs, midlevel practitioners, and physicians regarding his diagnosis of dementia, confusion, lack of orientation, and behavioral problems.

Patient #23's medical record included a "Medical Record Release Form," dated 10/06/17. The release form was signed by Patient #23 despite his documented cognitive deficits. It could not be determined if Patient #23 had the mental capacity to consent to a release of his medical information.

The CNO was interviewed on 4/05/18, beginning at 11:01 AM, and Patient #23's medical record was reviewed in her presence. She confirmed Patient #23 should not have signed his own release of information form. The CNO stated it was her expectation, for confused and/or incompetent patients, to involve the patient's legal representative for consent issues and information disclosure.

The CAH failed to ensure a ensure properly executed consent for release of medical information was performed for Patient #23.

Based on staff interview and review of quality assurance documents, it was determined the CAH failed to ensure an effective quality assurance program was maintained. This prevented the CAH from adequately evaluating its services. Findings include:

The Quality Manager was interviewed on 4/04/18 beginning at 1:20 PM. The surveyor requested a current comprehensive quality plan and minutes of the CAH's quality committee from 4/01/17 to 3/31/18. The Manager stated the CAH did not have a comprehensive quality plan. She also stated the CAH did not have a general quality committee so she stated there were no minutes. She provided the surveyor with a report that stated, "These are the reviewed and approved Department Annual Reports for FY 2016. The FY 2017 reports are a working copy/draft and have not been approved." She stated she could not provide documentation of departmental reports after 9/30/16. (Note: The CAH's fiscal year ran from October 1 through September 30.)

The CAH was able to produce current data for CMS required quality improvement programs including Consumer Assessment of Healthcare Providers and Systems and Merit-based Incentive Payment System programs. But the CAH was not able to provide current data or quality indicators from its departmental quality program.

The CAH failed to maintain an effective quality assurance program.

Based on staff interview and review of incident reports, it was determined the CAH failed to ensure remedial action to address deficiencies found through the quality assurance program. This resulted in


1. Incident reports were reviewed on 4/05/18. Two of six non-fall incident reports did not contain documentation the incidents were investigated or corrective action was taken.

A "Patient/Incident Report," dated 3/15/18, stated a patient spent a significant amount of "unnecessary" time under general anesthesia while waiting for the surgeon. It is generally accepted that increased time under anesthesia increases the risk of complications.

No investigation of the incident was documented. No action to prevent similar incidents from occurring was documented.

The CEO was interviewed on 4/05/18 beginning at 11:30 AM. He stated plans were in process to prevent future incidents of this type. However, he stated these plans were not documented. He stated he would be meeting with the physician involved in the incident but he said this meeting had not occurred.

The CAH failed to take timely corrective action to address problems identified by the incident report.

2. A "Patient/Incident Report," dated 3/21/18, stated a patient was discharged after surgery however before an x-ray that had been taken was checked to verify the results of the surgery.

No investigation of the incident was documented. No action to prevent similar incidents from occurring was documented.

The CEO was interviewed on 4/05/18 beginning at 11:30 AM. He stated he thought the incident was a result of an EMR problem. He stated he thought a new process was in place but he stated this was not documented.

The CAH failed to take corrective action to address problems identified by the incident report.

Based on OPO agreement review, Eye Bank agreement review, and staff interview, it was determined the CAH failed to work cooperatively with the designated OPO and Eye Bank in educating staff on donation issues. This failure had the potential for CAH staff to not identify potential donors, as well as failure to inform potential donor families of their donation options. Findings include:

The CAH OPO agreement stated "With the support of Hospital administration, [name of OPO] will provide Hospital education for hospital staff by providing educational programs, in-services, and attending skills day when invited by the Hospital. These educational services are available to the Hospital at least annually, but may occur more frequently per hospital needs."

The CAH Eye Bank agreement stated "[name of Eye Bank] RESPONSIBILITIES: Provide [name of CAH] with periodic education to hospital [sic] medical [sic] and nursing staff members regarding eye donation."

The CNO was interviewed on 4/05/18, beginning at 10:29 AM, and the OPO and Eye Bank agreements were reviewed in her presence. When asked if the OPO or Eye Bank had provided ongoing staff education to CAH employees, she stated no. The CNO stated she was unsure when education by either entity was provided or documented.

The CAH failed to work with the OPO and Eye Bank to provide staff education regarding donation issues.

Based on medical record review and staff interview, it was determined the CAH failed to ensure an ongoing program of activities for 3 of 3 swing bed patients (#18, #23, and #24) whose records were reviewed. This failure resulted in a lack of recreational activities, and had the potential to result in unmet patient needs for all swing bed patients. Findings include:

CAH swing bed patients were not provided activities. Examples include:

1. Patient #24 was an 88 year old male who was admitted to the CAH on 11/10/17, with a swing bed diagnosis of right femur fracture.

Patient #24's medical record included documented swing bed inpatient status from 11/10/17 to 12/08/17; a total of 29 days. Patient #24's medical record did not include an activities assessment or activities plan. Activities were not documented for Patient #24 during his 29-day inpatient swing bed admission.

2. Patient #18 was a 77 year old male who was admitted to the CAH on 11/10/17, with a swing bed diagnosis of lumbar fracture.

Patient #18's medical record included documented swing bed inpatient status from 11/10/17 to 12/06/17; a total of 27 days. Patient #18's medical record did not include an activities assessment or activities plan. Activities were not documented for Patient #18 during his 27-day inpatient swing bed admission.

3. Patient #23 was a 97 year old male who was admitted to the CAH on 10/05/17, with a swing bed diagnosis of dementia.

Patient #23's medical record included documented swing bed inpatient status from 10/09/17 to 10/17/17; a total of 9 days. Patient #23's medical record did not include an activities assessment or activities plan. Activities were not documented for Patient #23 during his 9-day inpatient swing bed admission.

The CNO was interviewed on 4/04/18, beginning at 1:40 PM, and Patients #18, #23, and #24 medical records were reviewed in her presence. She confirmed activity assessments, activity plans, and provided activities were not documented for these patients during their inpatient swing bed admissions.

The CAH failed to ensure activities for swing bed patients were provided.

Based on medical record review and staff interview, it was determined the CAH failed to ensure discharge summaries were present for 2 of 3 swing bed patients (#23 and #24) whose records were reviewed. This failure resulted in incomplete clinical documentation and had the potential to impact continuity of care. Findings include:

1. Patient #24 was an 88 year old male admitted to the facility on 11/10/17, with a swing bed diagnosis of right femur fracture. He was discharged home on 12/08/18.

Patient #24's medical record did not include a discharge summary.

2. Patient #23 was a 97 year old male who was admitted to the CAH on 10/05/17, with a swing bed diagnosis of dementia. He was discharged home on 10/17/17.

Patient #23's medical record did not include a discharge summary.

The CNO was interviewed on 4/05/18, beginning at 11:01 AM, and Patients #23 and #24 medical records were reviewed in her presence. She confirmed their medical records did not include a swing bed discharge summary.

The CAH failed to ensure discharge summaries were documented for swing bed patients.