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Based on observation, staff interview, and review of medical records, bylaws, policies, and meeting minutes, it was determined the hospital failed to ensure the Governing Body was effective and assumed responsibility for the conduct of the hospital. This resulted in the inability of the Governing Body to direct staff in the provision of patient care. It had the potential to impact all patients who received care at the hospital. Findings include:

1. The "Idaho Doctors Hospital Bylaws," dated 11/24/06, stated hospital board meeting would be held quarterly.

Meeting minutes for the hospital board documented 2 meetings in 2014, 2 in 2015, and 2 in 2016. The 2 board meeting minutes in 2014 and the 2/26/15 minutes discussed patient satisfaction scores. The 2 board meeting minutes in 2014 discussed plan review such as the utilization review plan and the performance improvement plan and also discussed medical staff credentialing. The 4/30/15 board meeting minutes discussed appointment of medical staff. Two board meetings were documented in 2016, on 1/28/16 and on 2/11/16. The 1/28/16 meeting was an emergency meeting. The 2 meeting minutes in 2016 documented discussion of financial and personnel issues. Except for the patient satisfaction discussions and review of plans, the board meeting minutes for 2 years and 9 months did not document that care at the hospital was discussed.

The Chairman of the Governing Body was interviewed on 9/29/16 beginning at 12:00 noon. He stated there was no documentation that the Board of Trustees had performed activities to demonstrate oversight of care and services at the hospital in at least the past year.

The Governing Body failed to assume responsibility for care and services at the hospital.

2. The Governing Body failed to ensure IDH adopted policies specific to the hospital.

Policies and forms that were presented as belonging to the hospital included the name of the affiliate CAH and a SNF. The policies did not reference the name of the hospital. Examples include:
- "HIM Department Chart Checklist," undated
- "Discharging Procedure/ Planning for Surgical Services," dated 3/20/13
- "Legibility of Medical Record Documentation," dated 1/14/14
- "Emergency Airway Equipment in the Operating Room," dated 7/05/10
- "Informed Consent (Anesthesia), dated 6/05/09
- "Environmental Monitoring," dated 7/15/16
- "Role and Functions of Sterile Processing," dated 4/23/13
- "Processing of Instrument and Pre-Sterilization of Procedure," dated 11/02/15
- "Handling of Emergency or Critical Patients," dated 5/28/09
- "Chemical Dispensing for Washers," dated 8/29/13
- "Cleaning of Sterilizers," dated 6/20/14
- "Department Cleaning," dated 11/02/15
- "3 + 3 Sterilizer Test after Maintenance," dated 10/07/15
- "Physician Orders/Read Back of Verbal/Telephone Orders," dated 5/19/16
- "Assessment Prior to Induction of Anesthesia/Sedation," dated 8/19/10
- "Patient Identification," dated 12/10/10
- "Security of Medications - Anesthesia Carts," dated 10/15/13
- "Scope of Services of the Surgical Services Department," dated 10/13/15
- "Physician Visits and CRNA in PACU," dated 6/05/09
- "Post Anesthesia Care (Comparable Level of Care)," dated 6/05/09
- "Procedure Consents," dated 4/27/15
- "Operating Room Rules and Regulations," dated 10/13/15
- "Narcotics and Stocked Drugs in PACU," dated 2/10/15
- "Medication Reconciliation," dated 2/01/13
- "Interventional Time Out," dated 1/03/13
- "Medical and Nursing Management in the PACU," dated 4/23/13
- "PACU Scoring Guidelines," dated 3/20/13
- "Post-Operative Care Following Discharge from PACU," dated 2/26/16
- "Infection Prevention and Control Measures Surgical," dated 6/05/13
- "Assessment Prior to Induction of Anesthesia/Sedation," dated 8/19/10
- "Clinic Instrument Cleaning and Transportation," dated 4/21/16
- "Comprehensive Care Plans," dated 11/26/12
- "Critical Value Communication - Lab Values," dated 10/22/15
- "Function of the Diabetes Educator," dated 3/30/16

The DSS was interviewed on 9/28/16 at 8:35 AM. He stated the "Clinical Practice Council" was in the process of reviewing and updating policies.

The Governing Body did not ensure IDH adopted policies specific to the hospital.

3. During an observation of Patient #21's neck surgery on 9/27/16 beginning at 8:06 AM, it was noted the Surgical First Assist, a physician assistant, harvested bone from Patient #21's hip as part of the procedure.

During a review of credentials files on 9/29/16 beginning at 2:20 PM, it was noted the Surgical First Assist, who harvested the bone, did not have privileges to perform this procedure.

The Medical Staff Services Director was interviewed during the credentials file review. She confirmed the Surgical First Assist's file did not include privileges to perform bone harvesting. She stated all Surgical First Assists had a core set of privileges and none had special privileges for procedures they performed, such as bone harvesting. She stated the medical staff did not think Surgical First Assists needed specific privileges for procedures in which the physician was providing direct supervision.

The Governing Body did not grant complete privileges to practitioners.

4. Refer to A057 as it relates to the failure of the Governing Body to ensure the CEO was responsible for managing the hospital.

5. Refer to A093 as it relates to the failure of the Governing Body to ensure the medical staff had written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate.

6. Refer to A263 as it relates to the failure of the Governing Body to ensure an effective, ongoing, hospital-wide, data-driven QAPI program was developed and implemented.

7. Refer to A338 as it relates to the failure of the Governing Body to ensure the Medical Staff operated under bylaws approved by the Governing Body, and was responsible for the quality of medical care provided to patients by the hospital.

8. Refer to A799 as it relates to the failure of the Governing Body to ensure a discharge planning process had been developed and implemented, and written policies and procedures were specified.

The cumulative effect of these systemic practices severely limited the hospitals ability to provide quality services to patients.

Based on staff interview, review of policies, and review of QAPI documents, it was determined the hospital failed to ensure an effective, ongoing, hospital-wide, data-driven QAPI program was developed and implemented. It was also determined the hospital's Governing Body failed to provide leadership and oversight of the QAPI program. This resulted in the inability of the hospital to monitor the quality of services it provided. Findings include:

1. Refer to A273 as it relates to the failure of the hospital to ensure quality indicators were developed to assess processes of care, hospital services, and operations.

2. Refer to A283 as it relates to the failure of the hospital to ensure priorities for its performance improvement activities focused on high-risk, high-volume, or problem-prone areas.

3. Refer to A286 as it relates to the failure of the hospital to ensure adverse patient events were analyzed and actions were taken to prevent further incidents.

4. Refer to A297 as it relates to the failure of the hospital to ensure distinct performance improvement projects were conducted.

5. Refer to A309 as it relates to the failure of the hospital to ensure the governing body, medical staff, and administrative officials were responsible and accountable for ensuring an ongoing program for quality improvement and patient safety, was defined, implemented, and maintained.

The cumulative effect of these negative systemic practices prevented the hospital from evaluating the care and services it provided.

Based on staff interview and review of Medical Staff bylaws and meeting minutes, it was determined the hospital failed to ensure the Medical Staff operated under bylaws approved by the Governing Body, and was responsible for the quality of medical care provided to patients by the hospital. This severely limited the ability of the hospital to direct and supervise medical care. Findings include:

Refer to A347 as it relates to the failure of the hospital to ensure the Medical Staff was accountable to the Governing Body for the quality of the medical care provided to patients.

The cumulative effect of these negative systemic practices resulted in a lack of direction and oversight of medical care.

Based on staff interview, medical record review, and hospital policy review, it was determined the hospital failed to ensure a discharge planning process had been developed and implemented, and written policies and procedures were specified. This resulted in the inability of the hospital to provide comprehensive discharge planning services. Findings include:

1. A hospital policy "Discharge Plan," revised 1/27/15, stated discharge planning was an interdisciplinary process. The policy did not state who was in charge of that process. Additionally, the policy did not define the discharge planning process. For example, the policy stated the initial screening and assessment for discharge planning was conducted during the nursing admission assessment. However, the policy did not define what the screen consisted of and the policy did not include a procedure to direct staff in what action to take if a discharge planning evaluation was indicated. The policy did not define a discharge planning evaluation or who needed to complete it. The policy did not define a discharge plan or how it would be documented. The policy did not state how the hospital would evaluate its discharge planning process.

The RN Case Manager was interviewed on 9/29/16, beginning at 10:00 AM. She stated she provided discharge planning services for the hospital. She stated the policy did not define a discharge planning screen, discharge planning evaluation, or a discharge plan.

The hospital did not develop a discharge planning policy that defined the discharge planning process.

2. Refer to A800 as it relates to the failure of the hospital to ensure a system was developed to identify at an early stage of hospitalization all patients who were likely to suffer adverse health consequences upon discharge if there was no adequate discharge planning.

3. Refer to A806 as it relates to the failure of the hospital to ensure a system was developed to provide discharge planning evaluations to patients.

4. Refer to A818 as it relates to the failure of the hospital to ensure a system was implemented to develop complete discharge plans.

5. Refer to A820 as it relates to the failure of the hospital to ensure patients were counseled to prepare them for post-hospital care.

6. Refer to A843 as it relates to the failure of the hospital to ensure the discharge planning process was reassessed on an on-going basis to ensure that discharge plans were responsive to discharge needs.

The cumulative effect of these negative systemic practices prevented the hospital from implementing a complete discharge planning program.

Based on staff interview, review of contracts, and review of administrative documents, it was determined the hospital failed to ensure the CEO was responsible for managing the hospital. This resulted in a lack of leadership and oversight of hospital functions and had the potential to impact all patients who received care at the hospital. Findings include:

The "Management Services Agreement" between BMH and IDH was dated 10/06/06. The agreement stated BMH would provide "...all management, administrative, financial, human resource management information technology and systems, nutrition and cafeteria services, housekeeping and laundry services, and all other business services as are reasonably necessary and appropriate for the day-to-day administration of [IDH's] operations, in accordance with all federal and state laws, rules regulations and guidelines of applicable governmental agencies."

The CEO was interviewed on 9/29/16, beginning at 1:40 PM. He stated BMH, a critical access hospital in Blackfoot, Idaho, also owned part of IDH. The CEO stated he was the CEO for both facilities. He stated the time he spent managing IDH was not tracked but he thought it was 15 to 20% of his total time.

Documentation was not present to show that IDH had evaluated services provided under the management agreement. The CEO stated was not sure if IDH had a documented review of the services provided under the "Management Services Agreement."

The CEO confirmed the Governing Body and Medical Staff for IDH had not met in compliance with their respective bylaws for the past year. He stated the groups used to meet frequently but said they rarely met since July 2015. The CEO stated he was not aware IDH did not have its own QAPI Program. He stated he was not aware IDH did not have a complete discharge planning program. The CEO stated his efforts to manage IDH were not documented.

The CEO failed to assume responsibility for oversight of the hospital.

Based on staff interview, review of medical records, and review of hospital policies, it was determined the hospital failed to ensure the medical staff had written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. This affected the care of 1 of 1 patient (#17), whose record was reviewed for emergency treatment. This resulted in a lack of direction to staff regarding the handling of patients with potential emergency medical conditions. Findings include:

The hospital maintained a list of RNs who could provide medical screening examinations.

The policy "(IDH) Compliance-Emergency Medical Condition," effective 10/11/14, defined Emergency Medical Conditions as conditions that placed the health of an individual, pregnant woman, or unborn child in jeopardy. It stated persons with Emergency Medical Conditions were to be treated immediately. The policy did not state how a medical screening examination would be conducted. The policy did not state how an RN would rule out an emergency medical condition. The policy did not discuss the role of the Medical Staff in determining whether the patient had an emergency medical condition. Additionally, the policy stated a "medical screening examination would be conducted to determine what stage of labor a pregnant woman was in." However, the hospital did not have equipment or qualified personnel to make determinations about the stages of labor.

A list of patients was requested who had come to the hospital seeking care for a potential emergency and had received an emergency medical screening examination. There were no patients listed for 2015 or 2016. The last person who presented to the hospital seeking emergency care was Patient #17 in 2014.

Patient #17 was a 20 year old female. Patient #17's "Medical Screening Exam Form," dated 4/28/14 at 11:05 AM, was written by an RN. The form stated Patient #17 presented to the hospital seeking medical attention for a problem with "passing out for a while on/off. falling." The form stated her knee was "skinned" earlier that day. The form stated her blood pressure was 117/72 and her pulse was 121 beats per minute. The form stated she was alert and oriented. The exam did not include a history of the presenting problem, i.e. when did Patient #17 last pass out? What happens when she passes out? How many times has she passed out? Also, the exam did not include a neurological check.

The form did not state the RN consulted with a physician before discharging Patient #17. The form stated Patient #17 refused an ambulance and said she could walk to a local emergency department approximately 0.7 miles away.

The RN Charge Nurse on duty reviewed Patient #17's medical record and was interviewed on 9/28/16 beginning at 12:00 noon. She confirmed the documentation was the complete record. She stated the hospital did not have a policy that specified how to conduct a medical screening examination. She stated the hospital did not have a policy that stated who to call with the findings of the examination. She stated if she had questions about the examination, she would call the House Supervisor on duty at BMH.

Hospital policies did not provide sufficient guidance to nursing staff to perform a complete screening examination for Patient #17.

Based on review of policies and grievances and staff interview, it was determined the hospital failed to ensure a clear grievance process was established with appropriate definitions of complaints and grievances. This had the potential to lead to misidentification of grievances as complaints for all patients who were hospitalized whose complaints were not resolved by staff present at the time of the complaint. Misidentification of grievances as complaints had the potential to result in missed investigation, follow-up, and integration into the hospital's QAPI program for process improvement evaluation. Findings include:

A hospital policy "Patient Care Concern and Grievance Process," dated 3/19/15, was reviewed. It included the following definitions of complaints and grievances:

- "Complaints are patient care issues that can be resolved promptly and involve patient care staff. Complaints typically involve minor issues that do not require formal investigation or the peer review process. Complaints should be addressed immediately and informally whenever possible. Supervisors or managers should actively attempt to resolve complaints while patients are still in the facility. IDH staff commonly calls complaints 'Care Concerns'."

- "Grievances are issues that are not resolved while the patient is still in the facility. Grievances generally violate patient rights. The following are some issues that may become grievances:
- The patient feels they were discharged prematurely.
- Confidentiality of patient health information is questioned.
- The patient alleges that the facility did not obtain informed consent.
- The patient alleges abuse, neglect, or other unethical behavior.
- The staff did not notify the physician of patient care issues."

In the hospital's definitions, a complaint did not become a grievance if it was resolved during the patient's hospitalization, regardless of the period of time of the hospitalization. This is inconsistent with the regulatory definition of complaints and grievances (§482.13(a)(2)), where complaints regarding the patient's care become grievances when they are not resolved at the time of the complaint by staff present.

The hospital's definitions of complaints and grievances do not make clear that any complaint alleging non-compliance with CMS Hospital Conditions of Participation would be a grievance.

When asked for a list of complaints and grievances from the prior 12 months, there was no documentation provided of any complaints or grievances with the inpatient facility. There were two documented complaints from the outpatient clinic strictly related to billing issues and one complaint about medical care and diagnosis.

The DSS was interviewed on 9/26/16 at 3:15 PM. He stated there had not been any grievances related to the hospital, and there had been three from the outpatient area. During a second interview on 9/28/16 3:38 PM, the DSS reviewed the grievance policy alongside the surveyor and confirmed the definitions of grievances and complaints listed in policy.

The hospital did not have a clear grievance process that appropriately defined complaints and grievances.

Based on policy review and staff interview, it was determined the hospital failed to ensure grievances were reviewed by the governing body or by a grievances committee that had been delegated in writing by the governing body to be responsible to review and resolve grievances. This had the potential to interfere with the effective operation of a grievance process for all patients who received care in the hospital or hospital's clinic. Findings include:

A hospital policy "Patient Care Concern and Grievance Process," dated 3/19/15, was reviewed. There was no reference in policy to a grievance committee or the involvement of the governing body in reviewing and resolving grievances.

The DSS was interviewed on 9/28/16 at 3:38 PM. He stated that complaints get referred to managers for review and response. He stated the hospital had a high satisfaction rate and did not have any complaints or grievance in the hospital in the past year, except as it related to an outpatient clinic associated with the hospital.

The hospital did not ensure a process was established where grievances were reviewed and responded to by the governing body or a grievance committee delegated and approved by the governing body.

Based on review of patient rights information, hospital policy, and staff interview, it was determined the hospital failed to ensure a clearly explained procedure was established for the submission of a patient's written grievance to the hospital. This had the potential to interfere with the submission of a complaint or grievance for all patients/representatives who wanted to submit a written complaint/grievance to the hospital. Findings include:

A hospital policy "Patient Care Concern and Grievance Process," dated 3/19/15, was reviewed. It included:

"The following will be provided to the patient or significant other when possible:
- Whom the patient contacts to file a grievance.
- The form on which a grievance may be filed, verbal or written.
- Access to the online grievance form or to the paper form.
- What the organization grievance process entails.
- Time frames for review and resolution of grievance."

Patient rights information from patient admission packets was reviewed. The packet included a form, dated 3/18/13, and titled "Conditions of Admission to Idaho Doctors' Hospital." A section within the form was titled "Grievance Process." It stated "I understand that I may file a grievance with either the IDH Customer Liaison at [telephone number] or the [State Agency] at [telephone number]. The form did not address how to file a written complaint/grievance with the hospital, such as an address or form to complete, or whether email was an acceptable way to communicate a complaint or grievance.

The admission packet also included a form "Your Rights and Responsibilities as a Hospital Patient," dated 3/18/13. A section within the form was titled "Complaint Resolution." It stated "If you have a complaint, we would like to have the opportunity to resolve it. Our goal is to respond to your complaint in a timely manner with an appropriate and clear explanation. In the event that you desire assistance, please contact your Attending Physician, appropriate Department Manager or Administration. You also have the right to file your complaint/ grievance with [State agency]." An address and phone number were included for the State agency. The form did not address how to file a written complaint/grievance with the hospital, such as an address or form to complete, or whether email was an acceptable way to communicate a complaint or grievance.

The DSS was interviewed on 9/28/16 at 3:38 PM. He reviewed the forms and confirmed information was not provided in writing to patients as to how to file a written complaint/grievance.

Based on review of hospital policy, grievance documentation, and staff interview, it was determined the hospital failed to ensure written notice of response to a grievance was provided to 1 of 1 patient (#5) who submitted grievances and whose documentation was reviewed. This resulted in a violation of the patient's right to receive a written letter of response that described the investigation process and results. Findings include:

The policy "Patient Care Concern and Grievance Process," dated 3/19/15, was reviewed. It included the following:

"The patient will be provided with written notice of:
- The name of the individual responsible for investigating the grievance.
- The steps taken to investigate and resolve the grievance
- The final result of the grievance
- The date of grievance completions"

A list of complaints/grievances was requested for the prior 12 months. There were no documented complaints/grievance provided related to the main hospital campus. There were 3 complaints/grievances provided related to the outpatient clinic. Two of the three complaints/grievances were related to non-Medicare related billing issues and did not qualify as grievances or require a written response.

One grievance for Patient #5 alleged inappropriate medical care in the outpatient setting. Grievance documentation included evidence of an investigation and provision of a verbal response to Patient #5 by telephone. There was no documentation a written response was provided to Patient #5.

The DSS was interviewed on 9/28/16 at 3:57 PM. He confirmed a written letter of response was not provided to Patient #5. He stated they responded verbally to the allegations.

The hospital did not respond in writing to Patient #5's grievance.

Based on review of medical records, hospital policy, patient rights information, consents, and staff interview, it was determined the hospital failed to ensure patients were given an opportunity to formulate advance directives for 8 of 19 surgical patients (#2, #3, #6, #9, #10, #11, #13, and #15) whose records were reviewed. This had the potential to result in patients wishes not being addressed in the event they were not able to communicate for themselves. Findings include:

The patient admission packet was reviewed. It included a form, "Your Rights and Responsibilities as a Hospital Patient," dated 11/10/11. It stated "You have the right to make advanced care decisions in case you are unable to communicate your wishes."

The policy, "Advance Directives (Living Will)," dated 5/30/08, was reviewed. It stated "The patient/resident will be given information and the opportunity to complete advance directives if desired."

These policies were not followed. Examples include:

The "Conditions of Admission to Idaho Doctors' Hospital," dated 3/18/13, was used as an admission consent form. It had sections that addressed advance directives, as follows:
__Yes__No I have a "Durable Power of Attorney for Health Care" at this time.
__Yes__No I have a "Living Will" at this time."
__Yes__No I have been offered the option of completing the Advance Directives at this time

Patients, referenced below, answered "No" to all three questions, indicating they did not have advance directives and had not been offered the option of completing advance directives. Examples include:
- Patient #2 answered "No" to all three questions on 8/16/16.
- Patient #3 answered "No" to all three questions on 9/07/16.
- Patient #6 answered "No" to all three questions on 8/15/16.
- Patient #9 answered "No" to all three questions on 6/08/16.
- Patient #10 answered "No" to all three questions on 8/08/16.
- Patient #11 answered "No" to all three questions on 4/05/16.
- Patient #13 answered "No" to all three questions on 7/05/16.
- Patient #15 answered "No" to all three questions on 8/16/16.

A CNA, who routinely witnessed the admission consents where the advance directive information was documented, was interviewed on 9/30/16 at 9:27 AM. She stated she thought BMH provided information about advance directives but they did not do so, to her knowledge, at IDH.

A Nurse Manager was interviewed on 9/29/16 at 2:56 PM. He stated the admission consent should have documented advance directives had been offered when patients stated they did not have advance directives.

The hospital did not offer information related to advance directives to Patients #2, #3, #6, #9, #10, #11, #13, and #15, to support patient rights to formulate advance directives.

Based on review of patient rights information and staff interview, it was determined the hospital failed to inform patients of all of their visitation rights. This impacted 20 of 20 surgical patients (#s 1-4 and 6-21) whose records were reviewed. It had the potential to interfere with the exercise of visitation rights. Findings include:

Patient admission information was reviewed. The admission packet included an undated form, "Your Rights and Responsibilities as a Hospital Patient," that addressed visitation rights: It stated "You have the right to designate visitors of your choosing, whether or not the visitor is related by blood or marriage, unless no visitors are allowed or the facility reasonably determines that the presence of a particular visitor would endanger the health or safety of a patient, a member of the health facility staff or other visitor to the health facility, or would significantly disrupt the operations of the facility."

The visitation rights information did not specifically address the right to withdraw or deny such consent at any time.

The visitation rights information was reviewed on 9/28/16 at 4:00 PM with the hospital Administrator. He nodded agreement when the differences between the hospital's patient rights information and the language of the regulations was presented to him.

The visitation rights information provided to patients was incomplete.

Based on staff interview and review of policies and QAPI documents, it was determined the hospital failed to ensure quality indicators were developed to assess processes of care, hospital services, and operations. This resulted in the inability of the hospital to evaluate programs and systems of care. Findings include:

Idaho Doctors Hospital was part of a larger healthcare system which included another hospital, an off site surgical center associated with the other hospital, a skilled nursing facility, and a wound care center.

A policy labeled "BINGHAM MEMORIAL HOSPITAL, SKILLED NURSING AND REHABILITATION CENTER AND IDAHO DOCTORS HOSPITAL" was titled "Performance Improvement Plan." It was dated 1/16/14. The plan mentioned Bingham Memorial Hospital 8 times. It did not specifically mention Idaho Doctors Hospital. The plan stated Bingham Memorial Hospital had "...chosen the FOCUS PDSA model for improving systems and processes." It did not mention which system was chosen by Idaho Doctors Hospital.

The plan included a PI Committee. The plan stated the PI Committee would coordinate and oversee PI activities.

Eleven PI Committee meeting minutes were reviewed, dated from 8/28/15 to 8/25/16. PI Committee meeting minutes included over 150 quality indicators on a dashboard. The dashboard listed data for the indicators each month. Only 2 quality indicators were currently specific to Idaho IDH. These included "IDH-Discharge Development/Press Ganey Scores [and] IDH-What Medication is for." Both were based on patient satisfaction reports. A third indicator, "IDH-Listening Carefully to you" was measured in 2015 but had been discontinued. No other quality indicators were documented for Idaho Doctors Hospital. No objective data was collected. No analysis of systems or processes of care at Idaho Doctors Hospital were documented.

The Quality Director was interviewed on 9/29/16, beginning at 9:05 AM. She stated IDH did not have a specific quality plan. She confirmed the 2 quality indicators specific to Idaho Doctors Hospital.

The hospital did not develop a specific QAPI program that was sufficient to show measurable improvement in indicators that would improve health outcomes.

Based on staff interview and review of QAPI documents, it was determined the hospital failed to ensure priorities for its performance improvement activities focused on high-risk, high-volume, or problem-prone areas. This resulted in a lack of information from which to develop a comprehensive and effective QAPI program. Findings include:

A document that identified the high-risk, high-volume, or problem-prone areas used to develop the hospital's QAPI plan was not present.

The Quality Director was interviewed on 9/29/16 beginning at 9:05 AM. She stated the Idaho Doctors Hospital had not identified high-risk, high-volume, or problem-prone areas for its QAPI program.

The hospital did not identify high-risk, high-volume, or problem-prone areas and use the information to develop its QAPI program.

Based on medical record review, hospital incident report review, hospital policy review, and staff interview, it was determined the hospital failed to ensure adverse patient events were reported, analyzed, and actions were taken to prevent further incidents. This affected the care of 3 of 3 surgical patients (#1, #18, and #21) whose records were reviewed. This failure to report, analyze, and take actions to prevent future incidents interfered with the hospital's ability to keep patients safe. Findings include:

A hospital policy, "Occurrence Reporting," dated 1/15/14, was reviewed. It stated:
- "A reportable occurrence is a (potentially) significant incident or event which is inconsistent with the normal or expected operation of the hospital."
- "The occurrence will be reported on the Occurrence Report Form..."

Hospital incident reports for the last 12 months were requested from the Quality Director on 9/28/16. The Quality Director was interviewed on 9/29/16, at 11:00 AM. She stated the hospital had not had any incident reports documented for the last 12 months.

The following occurrences, identified during a review of medical records, were not reported in accordance with policy:

1. Patient #18 was a 40 year old male who was admitted on 7/22/16, for spinal surgery. His medical record included an anesthesia record, dated 7/22/16, and signed by the CRNA. The record documented Patient #18 lost approximately 3000 ml of blood during his posterior lumbar fusion surgery and required 4 units of PRBCs intraoperatively.

An occurrence report was not documented following the incident. An investigation of the care provided to Patient #18 was not conducted following the incident.

The Nurse Manager was interviewed on 9/29/16, at 3:05 PM, and Patient #18's chart was reviewed in his presence. He confirmed Patient #18's 3000 ml blood loss during surgery should have been captured and analyzed in an incident report. The Nurse Manager stated Patient #18's incident was inconsistent with the normal or expected operation of the hospital.

2. Patient #1's medical record documented a 44 year old female who had a lumbar fusion on 1/04/16. The Discharge Summary, dated 1/07/16, stated Patient #1 did not recover well following surgery. The summary stated she did not recover from anesthesia and required transfer to another hospital for a higher level of care.

An occurrence report was not documented following the incident. An investigation of the care provided to Patient #1 was not conducted following the incident.

The Quality Director was interviewed on 9/29/16, at 11:00 AM. She stated an occurrence report was not generated and an investigation was not conducted following Patient #1's incident. The Quality Director stated physician peer review had not been completed regarding this incident. She stated no occurrence reports had been filed for the hospital in the past year.

3. Patient #21 was a 43 year old female admitted to the hospital on 9/27/16, for spinal surgery.

A physician note, dated 9/13/16, indicated Patient #21 had presented on 9/13/16 for her scheduled surgery. However, the nurse anesthetist canceled the procedure on the day of surgery. There was no anesthesia provider note to indicate the reason for the cancellation. Additionally, there was no occurrence report documented related to the cancellation.

The surgeon who performed Patient #21's surgery was interviewed on 9/29/16, at 12:00 PM. He stated the CRNA canceled the surgery on 9/13/16, due to Patient #21's cardiac findings after she presented to the hospital. The surgeon stated Patient #21 was sent to a cardiologist for clearance prior to rescheduling the surgery. He described the event as "rare" to have a patient canceled on the date of surgery. The surgeon did not know if anyone documented an occurrence report, but stated he did not document one.

An occurrence report was not documented related to Patient #21's canceled surgery.

The hospital failed to ensure adverse patient events were analyzed and actions were taken to prevent further incidents.



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Based on staff interview, hospital policy review, and hospital meeting minutes review, it was determined the hospital failed to ensure distinct performance improvement projects were conducted. This interfered with the ability of the hospital to comprehensively review processes of care. Findings include:

The policy "Performance Improvement Plan," dated 1/16/14, did not mention performance improvement projects.

Eleven hospital PI Committee meeting minutes were reviewed, dated from 8/28/15 to 8/25/16. The meeting minutes provided did not refer to distinct performance improvement projects.

The Quality Director was interviewed on 9/29/16, beginning at 9:05 AM. She stated Idaho Doctors Hospital had not developed or conducted performance improvement projects for at least the year prior to survey.

The hospital did not conduct performance improvement projects.

Based on staff interview, hospital policy review, and hospital QAPI document review, it was determined the hospital failed to ensure the governing body was responsible and accountable for ensuring an ongoing program for quality improvement and patient safety that was defined, implemented, and maintained. This resulted in the inability of the hospital to evaluate programs and systems of care. Findings include:

1. The policy "BINGHAM MEMORIAL HOSPITAL, SKILLED NURSING AND REHABILITATION CENTER AND IDAHO DOCTORS HOSPITAL...Performance Improvement Plan," dated 1/16/14, stated "The Board of Trustees of Bingham Memorial Hospital has the ultimate responsibility for hospital performance. The policy did not reference the Governing Body of IDH and did not assign responsibility to the IDH board.

The Quality Director was interviewed on 10/07/16 at 1:45 PM. She stated the policy did not reference the assigned responsibilities to the Governing Body of IDH.

The hospital did not define the IDH Governing Body's responsibilities for the QAPI program.

2. Meeting minutes for the IDH Governing Body documented 2 meetings in 2014, 2 in 2015, and 2 in 2016. The 2 meeting minutes in 2014 and the 2/26/15 minutes discussed patient satisfaction scores. The 2 meeting minutes in 2014 discussed reviews for the performance improvement plan. Governing Body meeting minutes did not document QAPI data or information which was reviewed or discussed. Governing Body meeting minutes did not document its oversight of the hospital's QAPI program.

Hospital meeting minutes documented the Medical (Staff) Executive Committee had not met since 4/30/15. Documentation was not present to demonstrate the Medical Staff monitored or provided input into the hospital's QAPI program.

Documentation was not present to demonstrate the hospital's administrative officials were responsible and accountable for developing and maintaining a QAPI program specific to Idaho Doctors hospital.

The hospital's CEO was interviewed on 9/29/16, beginning at 1:40 PM. He stated he was not aware that Idaho Doctors Hospital needed a separate QAPI program apart from its associated health care entities.

The governing body, medical staff, and administrative officials did not assume responsibility for the hospital's QAPI program.

3. The QAPI Committee with the responsibility to oversee the QAPI Program had no members of the IDH Governing Body or Medical Staff as members of the committee. Documentation was not present that a member of the IDH Governing Body or Medical Staff participated on the committee from 8/01/15 to 8/31/16.

The Quality Director was interviewed on 9/29/16, beginning at 9:05 AM. She stated no member of the IDH Governing Body or Medical Staff participated on the QAPI Committee.

The hospital failed to ensure the Governing Body and the Medical Staff participated in the hospital's QAPI Committee.

Based on staff interview and review of Medical Staff bylaws and meeting minutes, it was determined the hospital failed to ensure the Medical Staff was accountable to the Governing Body for the quality of the medical care provided to patients. This resulted in a lack of leadership and oversight of care by the Medical Staff. Findings include:

"IDAHO DOCTORS HOSPITAL MEDICAL STAFF BYLAWS," revised 2/26/14, stated the Medical Staff would meet at least 2 times per year. The bylaws stated a Medical Executive Committee would supervise the activities and performance of the Medical Staff. The bylaws stated the Medical Executive Committee "shall meet at least 7 times during the calendar year."

Medical Staff meeting minutes were reviewed on 9/28/16. Medical Executive Committee meeting minutes stated the committee met 3 times in 2015, on 1/29/15, 2/26/15, and 4/30/15. No meetings were documented after 4/30/15. No record of Medical Staff activities or Medical Executive Committee activities were documented after 4/30/15. No meetings of the entire Medical Staff were documented in 2015 or 2016.

The Chief of the Medical Staff was interviewed on 9/29/16 beginning at 12:00 noon. He stated there was no documentation Medical Staff activities since 4/30/15, 17 months earlier. He stated no meetings were currently scheduled. He stated no other documentation was available to show how the Medical Staff was overseeing medical care at the hospital.

The Medical Staff did not follow its own bylaws regarding meetings. No record of Medical Staff activities was documented in the past 17 months. The Medical Staff was not accountable for its actions.

Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure nursing staff clarified unclear or incomplete medication orders for 12 of 19 surgical patients (#2, #7, #8, #9, #10, #12, #13, #14, #15, #18, #19, and #21) whose medical records were reviewed. This had the potential to interfere with the quality and safety of patient care. Findings include:

A hospital policy, "Physician Orders/Read Back of Verbal/Telephone Orders," dated 5/19/16, was reviewed. It included the following information:
- "All orders for medications shall include the name of the patient, date and time of the order, the name of the drug, strength, the dosage, the route, frequency of administration, and diagnosis, condition or indications for use, when applicable; quality, duration, special instructions for use, age and weight."
- "PRN Orders: 'as needed' or 'PRN' medications shall specify the indication(s) for use and be specific for dose and dosage frequency [sic]"
- "Incomplete, illegible, or unclear orders will be immediately clarified by the prescribing practitioner either in person or telephone order."
- "Pre-printed order:...If [sic] want to strike out something in the order sheet or delete it or add order on blank line then the physician needs to initial each place."

A hospital policy, "Pain Management," dated 5/29/14, was reviewed. It stated a numeric rating of 1-10 is used to measure pain intensity.
- 0 rating indicated no pain.
- 1-3 rating indicated mild pain that was nagging and annoying, but only slightly interfered with ADLs.
- 4-6 rating indicated moderate pain and interfered significantly with ADLs.
- 7-10 rating was considered severe pain, was very disabling, and the patient was unable to perform ADLs.

Unclear medication orders were not clarified. Examples include:

1. Patient #10 was a 47 year old female admitted to the hospital on 8/08/16, for spinal surgery.

Patient #10's "Neurosurgery Post-Op Orders," dated 8/08/16 and noted at 4:40 PM, included the following pain medication options:
Mild to moderate pain:
- Percocet 5/325 1 tablet PO every 4 hours PRN mild/moderate pain
- Percocet 10/325 1 tablet PO every 4 hours PRN mild/moderate pain
- Dilaudid 1 mg IM every 2 hours PRN mild/moderate breakthrough pain
- Vistaril 12.5 mg IM every 3 hours PRN mild/moderate pain (for analgesia augmentation)
Severe pain:
- Percocet 5/325 2 tablets PO every 4 hours PRN severe pain
- Percocet 10/325 2 tablets PO every 4 hours PRN severe pain
- Dilaudid 2 mg IM every 2 hours PRN severe breakthrough pain
- Vistaril 25 mg IM every 3 hours PRN severe pain (for analgesia augmentation)

It was unclear as to the criteria for choosing one pain medication over another when more than one medication was indicated for mild/moderate pain and for severe pain. It was unclear as to whether all of the medications could or could not be combined.

2. Patient #19 was a 54 year old male admitted to the hospital on 5/16/16, for spinal surgery.

a. Patient #19's "Post-Anesthesia Care Unit (PACU) Orders," dated 5/16/16 at 10:15 AM, included the following options for pain and nausea:
Pain:
- Fentanyl (no dose selected) IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >4 mL (200 mcg).
- Morphine (checked and then crossed out without initials)
- Hydromorphone (Dilaudid) 0.4 mg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >2 mg. Next to the Dilaudid order was a handwritten note "<8/10." There were no initials authenticating the addition to the pre-printed form.
- An illegible medication "prn >8/10 pain"
Nausea/Vomiting:
- Ondansetron (Zofran) 4 mg IV PRN nausea/vomiting x 1.
- Promethazine (Phenergan) 12.5 mg IV PRN nausea/vomiting. Notify Anesthesia.

The Fentanyl dosage was not included in the order. There were no initials written next to the crossed out morphine or the hand written pain scale to authenticate the deletion or addition by the practitioner, in accordance with policy. There was an illegible pain medication written related to the PRN pain medication to be given when pain was >8/10. The pain criteria indicated < 8 and >8 but it did not address a pain scale of 8. The Phenergan order stated to "Notify Anesthesia," but did not list any criteria for notification. It was unclear whether all of the pain medications could be combined or not and the sequence of medication administration. It was unclear whether both anti-nausea medications could be administered and the sequence of medication administration.

b. Patient #19's "Neurosurgery Post-Op Orders," dated 5/16/16 and noted at 12:30 PM, included the following pain medication orders:
Mild/moderate pain:
- Percocet 10/325 1 tablet PO every 4 hours PRN mild/moderate pain
- Dilaudid 1-2 mg IM every 2 hours PRN mild/moderate breakthrough pain
- Vistaril 12.5 mg IM every 3 hours PRN mild/moderate pain (for analgesia augmentation)
Severe pain:
- Percocet 10/325 2 tablets PO every 4 hours PRN severe pain
- Dilaudid 2 mg IM every 2 hours PRN severe breakthrough pain
- Vistaril 25 mg IM every 3 hours PRN severe pain
Unrated pain:
- Toradol 30 mg IV every 6 hours PRN pain x 2 doses

It was unclear as to whether all pain medications could be combined or not and the sequence of pain medication administration when more than one pain medication was ordered for the same indication. The Toradol order was unclear as it did not indicate criteria for pain, such as level or type of pain.

3. Patient #13 was a 54 year old female admitted to the hospital on 7/05/16, for spinal surgery.

Patient #13's "Post-Anesthesia Care Unit (PACU) Orders," dated 7/05/16 at 7:05 AM, included the following pain medication orders:
- Fentanyl 50 mcg (1 mL) IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose 4 ml (200 mcg). The word "lst" was handwritten next to the Fentanyl order.
- Hydromorphone (Dilaudid) 0.4 mg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >2 mg. The word "2nd" was handwritten next to the Dilaudid order.

There were no initials written next to the handwritten words "lst" and "2nd" to authenticate the additions to the pre-printed order set.

4. Patient #15 was a 45 year old male who was admitted to the hospital on 8/16/16, for spinal surgery.

Patient #15's "Post-Anesthesia Care Unit (PACU) Orders," dated 8/16/16 at 11:05 AM, included the following orders for pain and nausea/vomiting:
Pain:
- Fentanyl 50 mcg (1 mL) IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >4 mL (200 mcg).
- Hydromorphone (Dilaudid) 0.4 mg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >2 mg. "<8/10" was handwritten next to the Dilaudid order.
Nausea/vomiting:
- Ondansetron (Zofran) 4 mg IV PRN nausea/vomiting x 1
- Promethazine (Phenergan) 12.5 mg IV PRN nausea/vomiting. Notify Anesthesia.

The handwritten pain scale added to the pre-printed orders, was not authenticated with initials in accordance with hospital policy. It was unclear how the nurse was to determine whether pain medications could be combined or not and the sequence of medication administration. It was also unclear how the nurse was to determine which medication, whether Zofran or Phenergan, was to be administered for nausea/and vomiting, and whether both could be administered. Although the Phenergan order stated to "Notify Anesthesia," it did not include criteria for notification.


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5. Patient #21 was a 41 year old female admitted to the hospital on 9/27/16, for spinal surgery.

Patient #21's "Post-Anesthesia Care Unit (PACU) Orders," dated 9/27/16 at 7:30 AM, included the following medication options for pain and nausea:
Pain:
- Fentanyl 25 mcg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >4 mL (200 mcg).
- Hydromorphone (Dilaudid) 0.2 mg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >2 mg. Next to the Dilaudid order was a handwritten note "<8/10." There were no initials authenticating the addition to the pre-printed form.
Nausea/Vomiting:
- Ondansetron (Zofran) 4 mg IV PRN nausea/vomiting x 1. The number "2" was handwritten next to the Ondansetron order.
- Promethazine (Phenergan) 12.5 mg IV PRN nausea/vomiting. Notify Anesthesia. The number "1" was handwritten next to the Promethazine order.

There were no initials written next to the hand written notes "< 8/10," "1," or "2" to authenticate the hand written additions to the pre-printed orders, in accordance with policy. The pain criteria, per policy, indicated < 8 and >8 but it did not address a pain scale of 8. It was unclear whether all of the pain medications could be combined or not and the sequence of medication administration. The Phenergan order stated to "Notify Anesthesia," but did not list any criteria for notification. Additionally, the Phenergan order did not have a frequency. It was unclear whether both anti-nausea medications could be administered and the sequence of medication administration.

6. Patient #14 was a 62 year old female admitted to the hospital on 6/13/16, for spinal surgery.

Patient #14's "Post-Anesthesia Care Unit (PACU) Orders," dated 6/13/16 at 10:00 AM, included the following medication options for pain and nausea:
Pain:
Nausea/Vomiting:
- Promethazine (Phenergan) 6.25 mg IV PRN nausea/vomiting. Notify Anesthesia.

The Phenergan order stated to "Notify Anesthesia," but did not list any criteria for notification. Additionally, the Phenergan order did not have a frequency.

7. Patient #12 was a 60 year old female admitted to the hospital on 8/03/16, for spinal surgery.

Patient #12's "Post-Anesthesia Care Unit (PACU) Orders," dated 8/03/16 at 8:00 AM, included the following medication options for nausea:
Nausea/Vomiting:
- Promethazine (Phenergan) 6.25 mg IV PRN nausea/vomiting. Notify Anesthesia.

The Phenergan order stated to "Notify Anesthesia," but did not list any criteria for notification. Additionally, the Phenergan order did not have a frequency.

8. Patient #9 was a 40 year old female admitted to the hospital on 6/08/16, for spinal surgery.

Patient #9's "Post-Anesthesia Care Unit (PACU) Orders," dated 6/08/16 at 7:30 AM, included the following medication options for pain and nausea:
Pain:
- Fentanyl 50 mcg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >4 mL (200 mcg). Next to the Dilaudid order was a handwritten note "1st."
- Hydromorphone (Dilaudid) 0.4 mg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >2 mg. Next to the Dilaudid order was a handwritten note "2nd."
Nausea/Vomiting:
- Promethazine (Phenergan) 6.25 mg IV PRN nausea/vomiting. Notify Anesthesia.

There were no initials written next to the handwritten "1st" or "2nd" to authenticate the addition by the practitioner, in accordance with policy. The pain criteria, per policy, indicated < 8 and >8 but it did not address a pain scale of 8. It was unclear whether all of the pain medications could be combined or not and the sequence of medication administration. The Phenergan order stated to "Notify Anesthesia," but did not list any criteria for notification. Additionally, the Phenergan order did not have a frequency.

9. Patient #7 was a 45 year old female admitted to the hospital on 6/13/16, for spinal surgery.

Patient #7's "Post-Anesthesia Care Unit (PACU) Orders," dated 6/13/16 at 2:00 PM, included the following medication options for pain:
Pain:
- Fentanyl 50 mcg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >4 mL (200 mcg). Next to the Dilaudid order was a handwritten note ">8."
- Hydromorphone (Dilaudid) 0.4 mg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >2 mg. Next to the Dilaudid order was a handwritten note "<8."

There were no initials written next to the handwritten ">8" or "<8" to authenticate the addition by the practitioner, in accordance with policy. The pain criteria, per policy, indicated < 8 and >8 but it did not address a pain scale of 8. It was unclear whether all of the pain medications could be combined or not and the sequence of medication administration.

10. Patient #8 was a 49 year old female admitted to the hospital on 6/13/16, for spinal surgery.

Patient #8's "Post-Anesthesia Care Unit (PACU) Orders," dated 6/13/16 at 7:59 AM, included the following medication options for pain:
Pain:
- Fentanyl 50 mcg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >4 mL (200 mcg).
- Hydromorphone (Dilaudid) (no dose selected) mg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >2 mg.

The Dilaudid dosage was not included in the order. The pain criteria, per policy, indicated < 8 and >8 but it did not address a pain scale of 8. It was unclear whether all of the pain medications could be combined or not and the sequence of medication administration.

11. Patient #2 was a 44 year old female admitted to the hospital on 8/16/16, for spinal surgery.

Patient #2's "Post-Anesthesia Care Unit (PACU) Orders," dated 8/16/16 at 8:30 AM, included the following medication options for pain and nausea:
Pain:
- Fentanyl 25 mcg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >4 mL (200 mcg).
- Hydromorphone (Dilaudid) 0.2 mg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >2 mg. Next to the Dilaudid order was a handwritten note "<8/10."
Nausea/Vomiting:
- Ondansetron (Zofran) 4 mg IV PRN nausea/vomiting x 1.
- Promethazine (Phenergan) 12.5 mg IV PRN nausea/vomiting. Notify Anesthesia.

There were no initials written next to the hand written "< 8/10" to authenticate the addition by the practitioner, in accordance with policy. The pain criteria, per policy, indicated < 8 and >8 but it did not address a pain scale of 8. It was unclear whether all of the pain medications could be combined or not and the sequence of medication administration. The Phenergan order stated to "Notify Anesthesia," but did not list any criteria for notification. Additionally, the Phenergan order did not have a frequency. It was unclear whether both anti-nausea medications could be administered and the sequence of medication administration.

12. Patient #18 was a 45 year old female admitted to the hospital on 7/22/16, for spinal surgery.

Patient #18's "Post-Anesthesia Care Unit (PACU) Orders," dated 7/22/16 at 10:30 AM, included the following options for pain and nausea:
Pain:
- Fentanyl 50 mcg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >4 mL (200 mcg). Next to the Dilaudid order was a handwritten note ">8."
- Hydromorphone (Dilaudid) 0.4 mg IV every 5 minutes PRN pain in PACU. Notify Anesthesia for dose >2 mg. Next to the Dilaudid order was a handwritten note "<8."
Nausea/Vomiting:
- Promethazine (Phenergan) 6.25 mg IV PRN nausea/vomiting. Notify Anesthesia.

There were no initials written next to the handwritten ">8" or "<8" to authenticate the addition by the practitioner, in accordance with policy. The pain criteria, per policy, indicated < 8 and >8 but it did not address a pain scale of 8. It was unclear whether all of the pain medications could be combined or not and the sequence of medication administration. The Phenergan order stated to "Notify Anesthesia," but did not list any criteria for notification. Additionally, the Phenergan order did not have a frequency.

A PACU RN was interviewed on 9/27/16, at approximately 9:30 AM, during which time she was providing care for Patient #21. When asked how she knew which pain medications to give when there were multiple orders, she stated the orders usually included a pain scale. She stated she had been a PACU nurse for 18 years and she knew what the CRNAs generally wanted. She also stated the CRNA was generally in another room (OR) nearby and she could ask questions if needed.

A CRNA was interviewed on 9/28/16, at 11:45 AM. He stated when writing orders for pain medication for PACU, he used a pain scale to guide the RN. He stated the orders should have criteria as to when to choose each medication.

An RN who worked on the floor after patients were moved from PACU was interviewed by telephone on 10/05/16, at 8:20 AM. When asked how she decided which pain medications to give when there were multiple choices ordered, she stated she did a pain assessment and often started with PO medications unless a patient was nauseated or pain was severe. She stated she primarily used nursing judgment. When asked if nursing staff had any algorithm or protocol to help with decision-making, she stated there wasn't any. She stated they used judgment, and it would be nice if there were more clear criteria.

A surgeon was interviewed on 9/29/16, at 12:00 PM. He stated the CRNA's orders for PACU ended when patients were moved to the floor. He stated orders for medications should be clear when they go to the floor. He thought the medication orders were generally clear.

Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure patient medical record entries were complete and legible for 4 of 19 surgical patients (#9, #12, #14, and #21) whose records were reviewed. This resulted in inconsistent documentation of patients' allergies and had the potential for unsafe medication administration for all hospital patients. Findings include:

A hospital policy "Legibility of Medical Record Documentation," effective 1/24/14, was reviewed. The policy included "It is the policy of BMH Inc., [sic] to set legibility standards for medical record documentation and to monitor compliance with these standards as part of our performance improvement and medical error reduction activities."

The hospital failed to follow their policy. Examples include:

1. Patient #21 was a 43 year old female admitted to the hospital on 9/27/16, for spinal surgery. Her medical record included a pre-anesthesia evaluation, dated 9/27/16, and signed by the CRNA. In the section titled "Allergies", it documented Patient #21 was allergic to morphine, demerol, and codeine. Her medical record also included neurosurgery post-operative orders, dated 9/27/16, and signed by the physician, which documented Patient #21 did not have allergies. Additionally, Patient #21's record included an anesthesia consent form, dated 9/27/16, signed by the CRNA, which documented she did not have allergies.

A Nurse Manager was interviewed on 9/29/16, at 3:24 PM. He confirmed Patient #21's allergies were documented inconsistently and impacted the safety of Patient #21.

2. Patient #12 was a 60 year old female admitted to the hospital on 8/03/16, for spinal surgery. Her medical record included a pre-anesthesia evaluation, dated 8/03/16, and signed by a CRNA. In the section titled "Allergies", it documented Patient #12 was allergic to morphine, Keflex, Levaquin, Relafen, sulfa, and Vancomycin. Additionally, there was an allergy documented in this section, but the writing was not legible. Her medical record also included a history and physical, dated 8/03/16, signed by the physician, which documented Patient #12 was allergic to tape, eggs, lactose, morphine, sulfa, and Vancomycin.

A Nurse Manager was interviewed on 9/29/16, at 3:28 PM. He confirmed Patient #12's allergies were documented inconsistently and impacted safety of Patient #12. The Nurse Manager stated he was unable to read the illegible allergy documented on the pre-anesthesia evaluation and confirmed it should have been clarified.

3. Patient #14 was a 62 year old female who was admitted to the hospital on 6/13/16, for spinal surgery. Her medical record included a pre-anesthesia evaluation, dated 6/13/16, and signed by a CRNA. In the section titled "Allergies", it was documented Patient 14 was allergic to Imitrex, latex, morphine, hydrocodone, aspirin, Flexeril, penicillin, and codeine. Her medical record also included a medication administration record, multiple dates, and signed by multiple RNs, which documented Patient #14 was allergic to tape, latex, aspirin, codeine, Flexeril, hydrocodone, morphine, penicillin, and sulfa.

A Nurse Manager was interviewed on 9/29/16, at 3:19 PM. He confirmed Patient #14's allergies were documented inconsistently and impacted the safety of Patient #14.

4. Patient #9 was a 40 year old female admitted to the hospital on 6/08/16, for spinal surgery. Her medical record included a pre-anesthesia evaluation, dated 6/08/16, and signed by a CRNA. In the section titled "Allergies", it was documented Patient #9 was allergic to codeine. Her medical record also included hospital admission orders, dated 6/08/16, and signed by the physician, which documented she had no allergies.

A Nurse Manager was interviewed on 9/29/16, at 3:36 PM. He confirmed Patient #9's allergies were documented inconsistently and could lead to poor outcomes.

The hospital failed to ensure patient safety, follow their policy, and ensure patient documentation was complete and legible.

Based on hospital policy review, hospital document review, and staff interview, it was determined the hospital failed to follow a hospital-specific system for identifying and reporting infections for post-discharge surgical patients and conduct active surveillance for monitoring hand hygiene. This had the potential for inaccurate infection rate tracking, reporting, and analysis. Findings include:

A hospital policy, "Handwashing and Hand Antisepsis," effective 6/21/2016, was reviewed. The policy included "The Infection Control Department at BMH will oversee the observation process, data collection and analysis of hand hygiene surveillance data. The actual observations are performed by observers from various disciplines. All observers for BMH will receive hand hygiene observation training by Infection Control, Employee Health or the Education Department."

A hospital policy, "Infection Control Plan," effective 2/24/16, was reviewed. The policy included "All patient care and patient care support departments/services and employee health services are included in this program." Additionally, the policy included "The Infection Control Committee will be responsible for reviewing, revising and approving, all policies and procedures related to the infection surveillance, prevention and control program for the facility. Reviews, revisions and approvals of policies are documented in the minutes of this committee." The policy also included "Education to employees and staff: Training for hand hygiene observers."

A hospital policy, "Cleaning Supplies and Chemicals," effective 4/21/09, was reviewed. The policy included "The Housekeeping Director and Infection Control Practitioner will review all products for any level of disinfection."

A hospital policy, "Performance Improvement Plan," effective 1/26/16, was reviewed. The policy included "Surgical site infection prevention."

The hospital failed to follow their policies. Examples include:

1. Hospital Infection Control Committee meeting minutes, dated 2/28/16, 3/17/16, 6/10/16, and 8/22/16, were reviewed. The meeting minutes included action items. The meeting minutes did not include any data or reference to IDH specifically.

2. A hospital document "BMH Infection Control Program Plan/Analysis 2016," dated 2/28/16, was reviewed. The plan included:
- Hand Hygiene
- CAUTI
- Employee Influenza Vaccination Rates
- Surgical Site Infection Prevention
- MDRO System
- CLABSI

IDH was included in Hand Hygiene, Employee Influenza Vaccination Rates, and Surgical Site Infection Prevention. IDH was not included in CAUTI, MDRO System, or CLABSI.

The plan/analysis combined BMH and IDH data. There was no plan/analysis specific to IDH.

3. A hospital document "IC Dashboard," undated, was reviewed. The dashboard included several NHSN items, which were tracked at BMH, and listed IDH as a department of BMH. The IC Dashboard combined BMH and IDH data. There was no IC Dashboard specific to IDH.

4. A hospital document "BMH Inc., & IDH Infection Prevention Plan 2016," undated, was reviewed. The plan included:
- Hand hygiene compliance
- Blood borne pathogen exposure and sharps safety
- Zika virus
- CAUTI
- C diff
- Employee influenza vaccination rate
- NHSN reporting

The Infection Prevention Plan combined BMH and IDH data. There was no Infection Prevention Plan specific to IDH.

The Infection Control Preventionist was interviewed on 9/27/16, at 2:03 PM. She stated she was unfamiliar with IDH specific policies. When asked if the provided infection control policies referred to BMH, IDH, or BMH and IDH combined, the ICP stated she was unsure. The ICP stated she allotted 5 to 6 hours per month at IDH for the purpose of infection control. She stated she did not perform infection control duties at the outpatient IDH departments of the Hyperbaric Center or Wound Care Clinic, and was unsure who did. Additionally, the ICP stated she did not currently have an infection control role in IDH food services or food services policies. She confirmed she did not currently have an infection control role regarding IDH approved cleaning agents or processes. The ICP confirmed the IDH specific infection control scope did not cover all inpatient and outpatient settings.

The ICP stated there was not a current hand hygiene surveillance program at IDH. She confirmed the hand hygiene data being presented to the Infection Control Committee under the "BMH Infection Control Program Plan/Analysis 2016" or "BMH Inc., & IDH Infection Prevention Plan 2016" did not include IDH, the Hyperbaric Center, or Wound Care Clinic. She confirmed the surgical site infection prevention data from the "BMH Infection Control Program Plan/Analysis 2016" did not apply to IDH. Additionally, the ICP confirmed the "IC Dashboard" did not separate IDH specific data from BMH data.

The ICP confirmed the Infection Control Committee meetings, which were conducted at BMH, did not separate IDH specific data from BMH data.

The ICP stated IDH patient post-discharge surgical infections were only reported if an outside physician notified her. The ICP stated she was unaware of a formal tracking measure to capture these infections and confirmed the aggregate data presented at Infection Control Committee meetings did not include data specific to IDH.

The Director of Quality was interviewed by phone on 10/05/16, at 1:35 PM. She stated IDH specific post-discharge surgical site infections were captured via "complication diagnosis codes" from clinic visits, return to OR, and return admissions. The Director of Quality stated IDH had not had any post-discharge surgical site infections for the past year, but if one was noted, the case would be sent to Peer Review and, if necessary, MEC. She stated IDH surgical site infections are listed on the BMH Infection Control Dashboard, but stated they are not discussed in Quality or Infection Control Committee meetings. She stated IDH data was not separated from BMH data.

Additionally, the Director of Quality stated the process for following IDH specific post-discharge surgical site infections was outlined in the PI plan policy. However, a process for identifying and reporting post-discharge surgical infections was not documented in this policy. The policy referenced BMH specifically several times, however IDH was not referenced.

The hospital failed to develop a system specific to the hospital for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Based on staff interview, medical record review, and hospital policy review, it was determined the hospital failed to ensure a system was developed to identify, at an early stage of hospitalization, all patients who were likely to suffer adverse health consequences upon discharge if there was no adequate discharge planning. This affected the care of 13 of 13 inpatients (#3, #4, #6, #7, #10, #11, #12, #13, #15, #18, #19, #20, and #21) whose records were reviewed. The lack of screening prevented the hospital from identifying patients who required discharge planning evaluations. Findings include:

A hospital policy "Discharge Plan," revised 1/27/15, stated the initial screening and assessment for discharge planning was conducted during the nursing admission assessment. However, the policy did not define what the screen consisted of and the policy did not include a procedure to direct staff in what action to take if a discharge planning evaluation was indicated.

Thirteen inpatient medical records (#3, #4, #6, #7, #10, #11, #12, #13, #15, #18, #19, #20, and #21) were reviewed for discharge planning services. None of these records documented an identifiable screen to determine whether the patient was likely to suffer adverse health consequences without adequate discharge planning.

The Charge RN on duty was interviewed on 9/28/16, beginning at 2:20 PM. She stated the hospital had not developed a screening process to identify which patients required a discharge planning evaluation. She stated nursing staff called patients the day prior to surgery and asked questions such as how many steps the patient's residence had and what kind of durable medical equipment the patient had. However, she stated this information was destroyed and was not kept as part of the medical record. She stated it would be good to have a list of questions to ask patients regarding discharge planning needs.

The hospital failed to develop a system to identify patients with discharge planning needs.

Based on staff interview, medical record review, and hospital policy review, it was determined the hospital failed to ensure a system was developed to provide discharge planning evaluations to patients. This affected the care of 13 of 13 inpatients (#3, #4, #6, #7, #10, #11, #12, #13, #15, #18, #19, #20, and #21) whose records were reviewed. The lack of a system to provide discharge planning evaluations prevented the hospital from identifying factors affecting the care of patients following discharge. Findings include:

A hospital policy "Discharge Plan," revised 1/27/15, stated all disciplines were involved in evaluating and planning to meet the physical, mental, and emotional needs of patients. The policy stated Case Management staff worked with the physician to assist in coordinating the discharge plan for each patient. The policy stated "When indicated, Case Management staff will assist the patient and the family in becoming more fully prepared to meet the demands of the transition from the acute care setting to home or to an alternate living arrangement, i.e. long term care, group home, shelter care." The policy did not define a discharge planning evaluation nor did it specifically state who needed to complete it.

Zero of 13 inpatient medical records that were reviewed, contained documentation of a discharge planning evaluation. Only 1 of those records (#6) documented involvement by Case Management staff.

Patient #6 was a 61 year old female who had back surgery on 8/15/16. She was discharged to a critical access hospital for swing bed care on 8/19/16.

A "Group Note" by an RN Case Manager, dated 8/18/16 at 9:44 AM, stated "Patient wishes to discharge to [name] hospital as Swingbed. Called to notify [hospital name] of admit date 8/19/16. Initial information faxed. Will follow up later this afternoon after [unknown acronym] orders completed." No other documentation by the Case Manager was present in Patient #6's record. No discharge planning evaluation was documented. No documentation of factors affecting the discharge plan was present.

The RN Case Manager was interviewed on 9/29/16, beginning at 10:00 AM. She stated she worked for a critical access hospital that contracted with IDH to provide discharge planning services. (This was not the critical access hospital Patient #6 was discharged to.) She confirmed the above note was the only case management note in Patient #6's record. She stated Patient #6 did not have a documented discharge planning evaluation. She stated she was not aware of a policy that defined discharge planning evaluations and said there was no form or list of questions that should be asked related to discharge planning needs. She stated she could not remember other patients who had received discharged planning services by a Case Manager in 2016. She stated she only provided services to IDH if they were requested by the RN and had a physician order.

The hospital failed to develop a system to provide discharge planning evaluations.

Based on staff interview, medical record review, and hospital policy review, it was determined the hospital failed to ensure a system had been implemented to develop complete discharge plans. This affected the care of 1 of 1 inpatient (#6) whose record was reviewed and who had a discharge plan. The lack of a system to provide discharge planning evaluations prevented the hospital from identifying factors affecting the care of patients following discharge. Findings include:

A hospital policy "Discharge Plan," revised 1/27/15, stated "...a treatment/care plan is developed that includes identifiable goals, objectives, and appropriate referrals." The policy did not specifically refer to a discharge plan or items that needed to be present in a discharge plan.

Patient #6 was a 61 year old female who had back surgery on 8/15/16. She was discharged to a critical access hospital for swing bed care on 8/19/16. While all patients had documented discharge instructions, Patient #6 was the only 1 of 13 inpatients whose records were reviewed who had a documented plan for care after surgery.

A "Group Note" by an RN Case Manager, dated 8/18/16 at 9:44 AM, stated "Patient wishes to discharge to [name] hospital as Swingbed. Called to notify [hospital name] of admit date 8/19/16. Initial information faxed. Will follow up later this afternoon after [unknown acronym] orders completed." No other documentation regarding a discharge plan was present in Patient #6's record. No documentation of factors affecting Patient #6's discharge plan was present in her record.

The RN Case Manager was interviewed on 9/29/16, beginning at 10:00 AM. She stated she was not aware of a policy that defined discharge plans. She reviewed Patient #6's record and confirmed no other documentation specific to her discharge plan was present.

The hospital failed to develop a system to develop discharge plans.

Based on staff interview and medical record review, it was determined the hospital failed to ensure 1 of 1 patient (#6), whose record was reviewed and who had a discharge plan, was counseled to prepare her for post-hospital care. Findings include:

Patient #6 was a 61 year old female who had back surgery on 8/15/16. She was discharged to a critical access hospital for swing bed care on 8/19/16.

A "Group Note" by an RN Case Manager, dated 8/18/16, at 9:44 AM, stated "Patient wishes to discharge to [name] hospital as Swingbed. Called to notify [hospital name] of admit date 8/19/16. Initial information faxed. Will follow up later this afternoon after [unknown acronym] orders completed." No documentation regarding counseling Patient #6 to prepare her for post-hospital care was present in her record.

The RN Case Manager was interviewed on 9/29/16, beginning at 10:00 AM. She stated there was no documentation that Patient #6 was counseled to prepare her for post-hospital care.

The hospital failed to counsel Patient #6 to prepare her for post-hospital care.

Based on staff interview and hospital quality indicator review, it was determined the hospital failed to ensure its discharge planning process was reassessed on an on-going basis, including a review of discharge plans to ensure they were responsive to discharge needs. This prevented the hospital from evaluating the effectiveness of its discharge planning process. Findings include:

The hospital's QAPI program did not include quality indicators for its discharge planning program.

The Quality Director was interviewed on 9/29/16, beginning at 9:05 AM. She stated IDH did not have quality indicators or a system to review discharge plans for effectiveness.

The RN Case Manager was interviewed on 9/29/16, beginning at 10:00 AM. She stated she was not aware of a system to review discharge plans for effectiveness.

The hospital failed to reassess discharge plans.

Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure a current H&P and/or evidence of an updated examination was completed prior to surgery for 1 of 19 surgical patients (#13) whose surgical records were reviewed. This had the potential to interfere with patient safety. Findings include:

A hospital policy, "History and Physical," dated 6/16/11, was reviewed. It stated the H&P "must be less than 30 days old and must be reviewed and updated prior to surgery or within 24 hours of admit if the patient is not having surgery."

Patient #13 was a 54 year old female admitted to the hospital on 7/05/16, for spine surgery. The H&P, dated 6/02/16, exceeded the 30 day requirement. A stamped, undated note, signed by the physician on the 6/02/16 H&P, indicated Patient #13's history and physical had been reviewed and Patient #13 had been evaluated. It did not indicate whether there had been any changes since the outdated H&P. There was no documentation by the physician or CRNA of a physical examination of Patient #13 prior to surgery.

A CRNA was interviewed on 9/28/16, at 11:45 AM. He stated the CRNA is supposed to listen to heart and lungs pre-operatively and document the assessment on the pre-anesthesia assessment form.

The hospital failed to ensure updated patient history and physical examinations were updated and current prior to surgery.

Based on medical record review, hospital policy review, and staff interview, the hospital failed to ensure surgical or anesthesia consent forms were properly executed for 13 of 13 patients (#2, #3, #7, #8, #9, #10, #12, #13, #14, #15, #18, #19, and #21) whose records were reviewed and who required consent. This resulted in a lack of clarity as to whether patients were appropriately informed prior to procedures. Findings include:

A hospital policy "Informed Consent (Anesthesia)," dated 6/05/09, included the following statements:
- "It is the anesthesiologist and/or CRNA's responsibility to obtain the informed consent for anesthesia."
- "The patient signs where indicated."
- "The date and time of signature is completed."

A hospital policy "Consent for Treatment," dated 9/28/15, included the following statements:
- "Responsibility for obtaining consent is the physician's."
- "All dates, times and signatures must in [sic] ink, including signatures of all witnesses."
- The consent form must include a "statement, if applicable, that other physicians...or other medical practitioners will perform important tasks related to the procedure."

Consent forms were not properly executed. Examples follow:

1. Patient #3 was a 66 year old male admitted to the hospital on 9/07/16, for spinal surgery.
The "Anesthesia and Procedure Consent Form," was signed by the CRNA on 9/07/16, at 7:05 AM. Patient #3's signature did not include a date and time.

The "Consent to Operation/Procedure and Other Medical Services," dated 9/07/16, was signed by Patient #3, without a corresponding date or time. The consent did not include the physician's signature.

2. Patient #10 was a 47 year old female admitted to the hospital on 8/08/16, for spinal surgery. The "Anesthesia and Procedure Consent Form," was signed by the CRNA on 8/08/16, at 11:31 AM. Patient #10's signature did not include a date and time.

3. Patient #13 was a 54 year old female admitted to the hospital on 7/05/16, for spinal surgery.

The "Anesthesia and Procedure Consent Form," was signed by the CRNA on 7/05/16, at 7:15 AM. Patient #13's signature did not include a date and time.

4. Patient #15 was a 45 year old male admitted to the hospital on 8/16/16, for spinal surgery.

The "Anesthesia and Procedure Consent Form," was signed by the CRNA on 8/16/16, at 10:05 AM. Patient #15's signature did not include a date and time.

The "CONSENT FOR SURGERY," was signed by Patient #15 and a witness on 7/19/16, at 3:53 PM. The consent did not include a physician's signature.

5. Patient #19 was a 54 year old male admitted to the hospital on 5/16/16, for spinal surgery.

The "Anesthesia and Procedure Consent Form," was signed by the CRNA on 5/16/16, at 8:52 AM. Patient #19's signature did not include a date and time.

6. Patient #21 was a 43 year old female admitted to the hospital on 9/27/16, for spinal surgery.

Patient #21's "Anesthesia and Procedure Consent Form," was signed by the CRNA on 9/27/16, at 7:30 AM. Patient #21's signature did not include a date and time.

7. Patient #14 was a 62 year old female admitted to the hospital on 6/13/16, for spinal surgery.

Patient #14's "Anesthesia and Procedure Consent Form," was signed by the CRNA on 6/13/16, at 9:20 AM. Patient #14's signature did not include a date and time.

8. Patient #12 was a 60 year old female admitted to the hospital on 8/03/16, for spinal surgery.

Patient #12's "Anesthesia and Procedure Consent Form," was signed by the CRNA on 8/03/16, at 7:10 AM. Patient #12's signature did not include a date and time.

Patient #12's medical record included a "Consent to Operation/Procedure and Other Medical Services," dated 8/03/16, and signed by Patient #12 and a witness. However, the consent did not include a physician signature. A date was documented at the top of the form while the signatures for Patient #12 and the witness were documented at the bottom. It was unclear if the date at the top of the form reflected the date the consent was filled out, signed by Patient #12 and the witness, or both.

9. Patient #7 was a 45 year old female admitted to the hospital on 6/13/16, for spinal surgery.

Patient #7's "Anesthesia and Procedure Consent Form," was signed by the CRNA on 6/13/16, at 1:20 PM. Patient #7's signature did not include a date and time.

10. Patient #9 was a 40 year old female admitted to the hospital on 6/08/16, for spinal surgery.

Patient #9's "Anesthesia and Procedure Consent Form," was signed by the CRNA on 6/08/16, at 7:29 AM. Patient #9's signature did not include a date and time.

Her medical record included a "Consent to Operation/Procedure and Other Medical Services," dated 6/08/16, and signed by Patient #9 and a witness. However, the consent did not include a documented physician signature or time. A date was documented at the top of the form while the signatures for Patient #9 and the witness were documented at the bottom. It was unclear if the date at the top of the form reflected the date the consent was filled out, signed by Patient #9 and the witness, or both.

11. Patient #8 was a 49 year old female admitted to the hospital on 6/13/16, for spinal surgery.

Patient #8's "Anesthesia and Procedure Consent Form," was signed by the CRNA on 6/13/16, at 7:09 AM. Patient #8's signature did not include a date and time.

12. Patient #18 was a 40 year old female admitted to the hospital on 7/22/16, for spinal surgery.

Patient #18's "Anesthesia and Procedure Consent Form," was signed by the CRNA on 7/22/16, at 9:20 AM. Patient #18's signature did not include a date and time.

13. Patient #2 was a 44 year old female admitted to the hospital on 8/16/16, for spinal surgery.

Patient #2's "Anesthesia and Procedure Consent Form," was signed by the CRNA on 8/16/16, at 7:20 AM. Patient #12's signature did not include a date and time.

Her medical record included a "Consent for Surgery," dated 7/19/16, and signed by Patient #2 and a witness. However, the consent did not include a physician signature.

The Nurse Manager was interviewed on 9/29/16, beginning at 2:56 PM. He stated the anesthesia consent form needed to be updated to include a place to date and time the patient signature. Currently, there was only one place to date and time a signature, underneath the CRNAs' signature. He stated the physician's signature should have been on the surgical consents.

The hospital failed to ensure consent forms for surgery and/or anesthesia were complete and properly executed.

Based on observation, hospital policy review, and staff interview, it was determined the hospital failed to ensure required emergency equipment was available to the operating room suites. This had the potential for adverse patient outcomes during a surgical emergency. Findings include:

A hospital policy "Emergency Airway Equipment in the Operating Room," effective 7/05/10, was reviewed. The policy included "Emergency tracheostomy supplies."

The hospital failed to follow their policy as follows:

An tour was conducted of the Operating Room on 9/26/16, beginning at 2:10 PM. During the observation, it was noted the Operating Room crash cart had an emergency cricothyroidotomy set, however an emergency tracheostomy set could not be located.

The Charge RN and Nurse Manager, who lead the Operating Room tour, were interviewed together on 9/26/16, at 3:00 PM. They confirmed the lack of an Operating Room emergency tracheostomy set.

The hospital failed to follow their policy and ensure required emergency equipment was available to the operating room suites.

Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure a pre-anesthesia examination was completed and documented prior to surgery for 1 of 19 surgical patients (#13) whose records were reviewed. This had the potential to interfere with patient safety. Findings include:

A hospital policy "Assessment Prior to Induction of Anesthesia/Sedation," dated 8/19/10, was reviewed. It stated "The patient will be evaluated by the anesthesiologist/anesthetist prior to provision of results of the evaluation documented on the pre-anesthesia evaluation record."

Patient #13 was a 54 year old female admitted to the hospital on 7/05/16, for spine surgery. There was no documentation of a heart or lung assessment by the CRNA prior to surgery.

A CRNA was interviewed on 9/28/16, at 11:45 AM. He stated the CRNA is supposed to listen to heart and lungs pre-operatively and document the assessment on the pre-anesthesia assessment form.

Patient #13's pre-anesthesia evaluation was incompletely documented.