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Based on staff interview and review of medical records and bylaws, it was determined the CAH's organizational structure was not sufficient to ensure systems were developed, implemented, and monitored in order to provide quality healthcare to patients. This resulted in the inability of the CAH to make certain staff were qualified and processes were monitored. Findings include:

1. Refer to C241 as it relates to the governing body's failure to ensure policies were implemented and monitored.

2. Refer to C330 Condition of Participation for Periodic Evaluation and Quality Assurance Review and related standard level deficiencies as they relate to the governing body's failure to ensure a periodic evaluation and quality assurance program had been developed and implemented.

The cumulative effect of these systemic deficient practices resulted in the CAH's inability to ensure quality care was provided and an inability to evaluate that care.

Based on staff interview and review of medical records, bylaws, and credentials files, it was determined the CAH's governing body failed to assume responsibility for implementing and monitoring compliance with policies. This had the potential to negatively impact the care of 3 of 3 sample patients (#43, #47, and #48) who were treated by the NP. Patient #43 was a newborn whose mother is Patient #41. Patient #47 was also a newborn whose mother is Patient #8. The lack of oversight had the potential to allow patients to be treated by unqualified personnel. Findings include:

Three patient medical records documented persons who were treated by the NP. These included:

a. Patient #8's medical record documented a 27 year old female who was admitted in labor on 4/23/14 and was discharged on 4/25/14. The record stated she delivered a baby boy (Patient #47) by cesarean section on 4/23/14. An untitled discharge summary, written by Patient #8's physician and dated 4/25/14 at 8:50 AM, stated Patient #8 "...was admitted for repeat cesarean section. Fetus was found to be in transverse presentation with very difficult and prolonged extraction requiring conversion from low transverse incision to classical. Hemorrhaging was occurring during delivery and 2 units of [red blood cells] were transfused during the procedure. Patient #8's "OPERATIVE REPORT," dated 4/23/14 at 10:09 AM, listed the NP as the "PEDIATRICIAN." The report stated the baby required resuscitation.

The newborn's record (Patient #47) contained an untitled birth note by the NP dated 4/23/14 at 9:48 AM. It stated Patient #47 required chest compressions and positive pressure ventilation for resuscitation immediately after birth. The baby continued to have difficulty breathing and was treated until at least 3:08 PM by the NP. A nursing progress note at 3:05 PM stated the NP suctioned Patient #47. A nursing progress note at 3:08 PM stated the NP ordered the nurse to take the continuous positive airway pressure machine off and see if the baby's oxygen saturation levels remained stable. Patient #47's condition continued to improve and he was discharged by a physician on 4/25/14.

b. Patient #41's medical record documented a 21 year old female who vaginally delivered twins on 1/20/14. The record stated 1 newborn was cared for by a physician at birth and the other newborn was cared for by the NP. The record of the newborn cared for the NP (Patient #43) documented an "Assessment Report" which contained a section titled "Assessment Name: Newborn Infant Attending Physician's Record," dated 1/20/14 at 11:44 PM. The assessment was completed by the NP.

c. Patient #48's medical record documented a 2 year old male who was admitted by the NP on 5/12/14 and discharged on 5/13/14. His diagnosis was pneumonia. The record documented he was admitted, cared for, and discharged by the NP. No documentation by another practitioner was present in the record.

Article 4 of the Bylaws for the Board of Trustees, dated 11/13/06, stated the Board's responsibilities included appointing persons to the medical staff and granting them privileges.

"Medical Staff Bylaws," dated 10/18/12, classified NPs as Allied Health Practitioners. The bylaws stated at Article 5.1, "...every practitioner and AHP providing clinical services at WMH shall only exercise those privileges specifically granted to him or her by the Governing Body...The Governing Body...shall identify those privileges that are available at WMH."

One NP practiced at the CAH. She was appointed to the Medical Staff on 1/23/14.

A document in the NP's credentials file, titled "SCOPE OF SERVICE FAMILY NURSE PRACTITIONER," dated 1/23/14, stated "CLINICAL DUTIES AND RESPONSIBILITIES: Diagnosing and treating continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body; Performing prenatal, well-child, and adult care check ups; Diagnosing and managing minor trauma...Formulate a treatment plan and evaluate patient response to treatment; Formulates patient treatment plans within the Nurse Practitioner's scope of education and license; Implements therapeutic interventions when appropriate within scope of education and license..."

The credentials file did not include documentation that the NP had been granted specific privileges by the hospital's Governing Board. Additionally, the file did not include documentation the NP had training to care for unstable and potentially unstable newborns.

The Medical Staff Coordinator was interviewed on 8/21/14 beginning at 3:40 PM. He confirmed the NP did not have specific privileges to practice at the CAH. He stated the NP was an independent practitioner and could practice at the CAH without supervision. He confirmed the NP had admitted and treated at least 3 patients on her own without supervision. He also confirmed the hospital did not have documentation the NP had been trained to care for unstable newborns.

The Chairman of the Board of Trustees was interviewed on 8/25/14 beginning at 10:10 AM. He stated the NP worked for a medical clinic whose physicians practiced at the CAH. He stated he was not aware the NP did not have specific privileges. He also stated he was not aware the NP had managed patients on her own. He stated patients had to be under the care of a physician.

The Board of Trustees failed to grant specific privileges to the NP and failed to ensure she practiced within those parameters.

2. Governing Board Bylaws, article 9, titled "MEDICAL STAFF" stated, "Every patient admitted to a District facility shall be under the care of a physician licensed by the Idaho State Board of Medicine." However, these bylaws were not enforced.

Patient #48's medical record documented a 2 year old male who was admitted by the NP on 5/12/14 and discharged on 5/13/14. His diagnosis was pneumonia. The record documented he was admitted, cared for, and discharged by the NP. No documentation by another practitioner was present in the record.
The Medical Staff Coordinator was interviewed on 8/21/14 beginning at 3:40 PM. He said the NP, hired on 1/23/14, had admitted, treated, and discharged 3 patients on her own without physician supervision, one of which was Patient #48. He stated he did not realize patients needed to be under the care of a physician.

The Chairman of the Board of Trustees was interviewed on 8/25/14 beginning at 10:10 AM. He stated the NP worked for a medical clinic whose physicians practiced at the hospital. He stated he was not aware the NP had managed patients on her own. He stated patients had to be under the care of a physician.

The Governing Body did not enforce bylaws requiring patients to be under the care of a physician.

Based on staff interview and observation of patient care, it was determined the facility failed to ensure the implementation of procedures to avoid potential transmission of infections and communicable diseases. This directly affected the care of 1 of 1 patient (#44) who was observed in pre-operative care, and had the potential to impact all patients. Failure to follow policies and standard precautions had the potential to allow for transmission of infections. Findings include:

The " INFECTION PREVENTION FACILITY-WIDE" policy, dated 2/2014, stated, "...hand hygiene is the single most important control measure in the prevention of the spread of infection. Wash hands with soap and water when visibly dirty or contaminated with pertinacious material, visibly soiled with blood or other body fluids. If hands are not visible soiled, wash hands; before and after any direct patient contact. Before and after donning gloves. After contact with body fluids or excreting mucous membranes, non-intact skin. Before handling invasive devices for patient care, regardless whether or not gloves used. If moving from a contaminated body site to a clean body site during patient care. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Before handling medication and preparing food."

On 8/25/14 beginning at 10:40 AM, an RN was observed on the MED/SURG floor, preparing Patient #44 for surgery. The RN entered Patient #44's room without first performing hand hygiene. The RN started Patient #44's assessment by asking questions regarding his medical history. She then checked his armband and verified his information. The RN picked up a stethoscope and listened to Patient #44's heart and lungs. She then placed a blood pressure cuff and oxygen saturation monitor on Patient #44's right arm. Upon completion, she put gloves on and cleaned the blood pressure cuff with a sanitizing wipe. She then removed her gloves and entered Patient #44's information on a portable computer. She did not perform hand hygiene before and after assessment of Patient #44. The RN then went to the supply cart located at the doorway of Patient #44's room. She gathered supplies and re-entered the room. The RN put gloves on and shaved Patient #44's surgical site. The RN then removed her gloves and went to the supplies, opened sequential compression device sleeves (device limits the development of deep vein thrombosis) and placed them on Patient #44's lower legs. She did not perform hand hygiene when leaving and re-entering Patient #44's room. The RN gathered supplies to start an intravenous infusion. She hung a intravenous fluid bag on a pole and removed the port cap. She then opened the intravenous tubing and spiked the tubing into the intravenous fluid bag. She flushed the tubing with the fluid and hung the tubing on the pole. The RN opened the intravenous catheter and cover dressing. She opened a syringe and withdrew lidocaine. The RN put gloves on and inserted the intravenous catheter into Patient #44's right hand. She withdrew the needle and placed it on the patient's bedside table. Once the intravenous fluid was infusing she secured the catheter site. The RN took her gloves off and began to clean up the bedside table. She picked up the intravenous catheter needle with her bare hands (blood was observed on the needle) and placed it into a sharps container. The RN returned to the bedside table and cleaned the blood off of the table top with a alcohol swab, using her bare hands. She did not perform hand hygiene before and after gloving. The RN did not use personal protective equipment (gloves) when in contact with blood. The RN returned to the portable computer and entered more information. She then left Patient #44's room. She did not perform hand hygiene when leaving Patient #44's room.

The RN was interviewed on 8/25/14 at 3:15 PM. She confirmed she did not follow hospital policy for hand hygiene.

Infection control practices consistent with the CAH's policy were not observed.

Based on observation and interview, it was determined the facility failed to ensure that, prior to receiving anesthesia, patients were examined to evaluate the potential risks. This impacted 1 of 1 patient (#44) whose surgery was observed. This had the potential to result in negative patient outcome. Findings include:

Patient #44 was a 49 year old male admitted to the facility on 8/25/14 for right inguinal hernia repair and screening colonoscopy.

On 8/25/14, beginning at 11:30 AM, Patient #44 was observed in his room as an RN was preparing him for surgery. At approximately 12:30 PM, the CRNA was observed to introduce himself to Patient #44. He asked Patient #44 if he had any prior issues with anesthesia, when he had last had anything by mouth, and about his health history. Patient #44 was then transferred to the OR. The CRNA did not listen to Patient #44's heart and lungs with a stethoscope before he was taken to the OR.

The CRNA was interviewed on 8/25/14 at 2:45 PM. He confirmed that he should have completed a physical examination of Patient #44.

Patient #44 did not receive a pre-anesthesia evaluation.

Based on staff interview and review of hospital policies and quality documents, it was determined the CAH failed to ensure a periodic evaluation and quality assurance program had been developed and implemented. This resulted in the inability of the CAH to assess its services, identify areas needing improvement, and take steps to improve and monitor quality. Findings include:

1. Refer to C331 as it relates to the failure of the CAH to ensure an evaluation of its total program had been completed.

2. Refer to C332 as it relates to the failure of the CAH to ensure a periodic evaluation of its total program, including the utilization of CAH services, was completed annually.

3. Refer to C333 as it relates to the failure of the CAH to ensure a periodic evaluation of its total program, including a sample of both active and closed clinical records, was completed annually.

4. Refer to C334 as it relates to the failure of the CAH to ensure a periodic evaluation of its total program, including review of the CAH's health care policies, was completed annually.

5. Refer to C335 as it relates to the failure of the CAH to ensure an evaluation had been conducted to determine whether the utilization of services was appropriate and policies were followed.

6. Refer to C337 as it relates to the failure of the CAH to ensure the QA program included an evaluation of all patient care services.

7. Refer to C339 as it relates to the failure of the CAH to ensure the appropriateness of the diagnosis and treatment by the nurse practitioner was evaluated.

The cumulative effect of these negative systemic omissions resulted in the inability of the CAH to evaluate the care and services it provided.

Based on staff interview and review of policies and quality assurance documents, it was determined the CAH failed to ensure an evaluation of its total program had been completed. This resulted in a lack of feedback to persons responsible for the operation of the CAH. Findings include:

Quality assurance documents were reviewed with the Quality Manager on 8/22/14 beginning at 2:00 PM. An evaluation of the CAH's total program was not present. The Quality Manager stated an evaluation of the CAH's total program had not been completed since at least 1/01/13. In addition he stated there was currently no Quality Plan or policy which specified the CAH would conduct an annual evaluation.

The CAH did not conduct an evaluation of its total program at least annually.

Based on staff interview and review of quality assurance documents, it was determined the CAH failed to ensure an evaluation of its total program had been completed and included the utilization of CAH services. This resulted the potential for under or over utilization of CAH services without of the knowledge of those responsible for the operation of the CAH. Findings include:

Quality assurance documents were reviewed with the Quality Manager on 8/22/14 beginning at 2:00 PM. No documents were available that included the utilization of CAH services. The Quality Manager stated an evaluation of the CAH's program including the utilization of CAH services had not been completed since at least 1/01/13.

An evaluation of the CAH's program including the utilization of services was not completed at least annually.

Based on staff interview and review of quality assurance documents, it was determined the CAH failed to conduct a review of the CAH's program including a review of clinical records. This resulted in the potential for unsafe and/or ineffective practices to continue without correction. Findings include:

Quality assurance documents were reviewed with the Quality Manager on 8/22/14 beginning at 2:00 PM. An evaluation of the CAH's program including a review of medical records was not present. The Quality Manager stated an evaluation of the CAH's program including a review of clinical records had not been completed since at least 1/01/13.

An evaluation of the CAH's program including a review of clinical records was not completed at least annually.

Based on staff interview and review of policies and quality assurance documents, it was determined the CAH failed to conduct an annual evaluation that included a review of healthcare policies. This resulted in the potential for policies directing staff to include outdated clinical practices. Findings include:

Quality assurance documents were reviewed with the Quality Manager on 8/22/14 beginning at 2:50 PM. An evaluation of the CAH's program including a review of policies was not documented. The Quality Manager stated that an evaluation including a review of policies had not been completed since 1/01/13.

An evaluation of the CAH's program including a review of policies was not completed annually.

Based on staff interview and review of quality assurance documents, it was determined the CAH failed to ensure an evaluation had been conducted to determine whether the utilization of services was appropriate, if policies were followed, and if changes were needed. This impeded the ability of the CAH to assess its services and had the potential to negatively impact the quality of patient care. Findings include:

Quality assurance documents were reviewed with the Quality Manager on 8/22/14 beginning at 2:00 PM. The Quality Manager stated an evaluation that included an evaluation service utilization and compliance with policies had not been completed since at least 1/01/13. In addition he stated there was currently no Quality Plan or policy which specified the CAH would conduct an annual evaluation and make changes based on the results.

An evaluation of the CAH's services and policies, was not completed to allow for changes to improve service quality.

Based on staff interview and review of QA documents, it was determined the CAH failed to ensure the QA program included an evaluation of all patient care services. This resulted in the potential for negative patient outcomes to go undetected. Findings include:

QA documents were reviewed with the Quality Manager on 8/22/14 beginning at 2:00 PM. The QA program did not contain quality indicators for the pharmacy, including the tracking of medication errors. It did not include quality indicators for surgical services. The Quality Manager confirmed the QA program did not include an evaluation of pharmacy and surgical services.

The CAH's QA program did not include an evaluation of all patient care services.

Based on staff interview, it was determined the CAH failed to ensure the appropriateness of the diagnosis and treatment by the NP was evaluated. This resulted the potential for patients' to receive inaccurate diagnoses and inappropriate care. Findings include:

The Quality Manager was interviewed on 8/23/14 beginning at 11:20 AM. The Quality Manager stated the NP, hired on 1/23/14, had admitted, treated, and discharged 3 patients on her own without physician supervision. When asked if any of those cases had been reviewed by a physician for the appropriateness of diagnosis and treatment, he checked a list of cases involved in the CAH's peer review program. He stated none of the NP's cases met criteria for review and so none of the NP's cases had been reviewed by a physician.

The CAH failed to review services provided by the NP for the appropriateness of diagnosis and treatment.

Based on staff interview and medical record review, it was determined the CAH failed to provide specialized rehabilitation services to 1 of 3 swing bed patients (#40) whose records were reviewed. This had the potential to delay the recovery of patients. Findings include:

Patient #40's medical record documented an 87 year old female who was admitted to swing bed status at 6:15 PM on 7/25/14. She was discharged on 8/03/14. The record stated she was initially to the CAH as an acute care patient on 7/21/14 after a fall where she laid on the floor for an extended period of time. Diagnoses included urinary tract infection and emphysema.

An order dated 7/25/14 at 5:42 PM called for OT to evaluate and treat Patient #40. No documentation was present in her record that she was seen by an Occupational Therapist during her stay. No further orders for therapy were documented.

The Clinical Technical Support Coordinator reviewed Patient #40's record and was interviewed on 8/25/14 beginning at 12:45 PM. She confirmed the order for OT services and stated no documentation was present that the order had been carried out.

The CAH did not provide OT services to Patient #40.

Based on staff interview, it was determined the CAH failed to ensure dental services were available to swing bed patients. This resulted in the potential for patients' dental needs to go unmet. Findings include:

The Social Worker who managed swing bed services at the CAH was interviewed on 8/25/14 beginning at 2:15 PM. She stated the CAH did not have a contract with a provider for dental services and such services were not available for swing bed patients.

Dental services were not available, as needed, for patients.