Every finding on record at Teton County Hospital District

Based on review of the emergency plan and staff interview, the facility failed to ensure the emergency plan addressed the patient population and the type of services the facility had the ability to provide in an emergency. The findings were: 1. During an interview on 12/16/21 at 2:11 PM the administrator stated the facility did not have their own separate policy for emergency preparedness and was using the home health agency's "Home Care" policy and the hospital's "Emergency Management Plan." She stated there would be no additional documentation to show the facility's plan addressed the patient population and services provided. 2. Review of the facility's policies "Emergency Management Plan" and "Home Care- Emergency Preparedness" (approved 11/11/21) showed neither addressed the patient population nor the services the facility could provide in an emergency.

Based on review of emergency preparedness policies and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed a procedure to follow up with on-duty staff and patients to determine services that are needed in the event there is an interruption in services during an emergency. In addition, there lacked a procedure to inform State and local officials of any on-duty staff or patients the facility was unable to contact. The findings were: 1. During an interview on 12/16/21 at 2:11 PM the administrator stated the facility did not have their own separate policy for emergency preparedness and was using the home health agency's "Home Care" policy and the hospital's "Emergency Management Plan." She stated there would be no additional documentation to show the facility had a procedure to follow-up with on-duty staff and patients or inform officials of any on-duty staff or patients the facility was unable to contact. 2. Review of the policies "Emergency Management Plan" and "Home Care- Emergency Preparedness" (approved 11/11/21) showed neither addressed a procedure to follow up with on-duty staff and patients to determine services that are needed in the event there is an interruption in services during an emergency. In addition, there lacked a procedure to inform State and local officials of any on-duty staff or patients the facility was unable to contact.

Based on review of emergency preparedness policies and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed a procedure to notify State and local emergency preparedness officials about hospice patients in need of evacuation from their residences due to an emergency situation. The findings were: 1. During an interview on 12/16/21 at 2:11 PM the administrator stated the facility did not have their own separate policy for emergency preparedness and was using the home health agency's "Home Care" policy and the hospital's "Emergency Management Plan." She stated there would be no additional documentation to show the facility had a procedure to notify officials about hospice patients in need of evacuation. 2. Review of the facility's policies "Emergency Management Plan" and "Home Care- Emergency Preparedness" (approved 11/11/21) showed no procedure to notify State and local emergency preparedness officials about hospice patients in need of evacuation from their residences due to an emergency situation.

Based on medical record review and staff interview, the facility failed to ensure information from the initial bereavement assessment was incorporated into the plan of care for 5 of 13 patients (#1, #2, #6, #7, #9). The findings were: 1. Review of the of the 12/8/21 initial assessment for patient #1 showed a bereavement assessment was completed. However, review of the plan of care (for certification period 12/8/21 to 3/7/22) showed bereavement was not addressed. 2. Review of the 12/2/21 initial assessment for patient #2 showed a bereavement assessment was completed. However, review of the plan of care (for certification period 11/2/21 to 1/30/22) showed bereavement was not addressed. 3. Review of the 11/16/21 initial assessment for patient #6 showed a bereavement assessment was completed. However, review of the plan of care (for certification period 11/16/21 to 2/13/21) showed bereavement was not addressed. 4. Review of the 10/19/21 initial assessment for patient #7 showed a bereavement assessment was completed. However, review of the plan of care (for certification period through 11/13/21) showed bereavement was not addressed. 5. Review of the 2/16/21 initial assessment for patient #9 showed a bereavement assessment was completed. However, review of the plan of care showed bereavement was not addressed. While reviewing the medical record with the surveyor on 12/16/21 at 10:50 AM the administrator confirmed the plan of care did not address findings from the bereavement assessment. 6. On 12/16/21 at 9:50 AM the administrator stated the interdisciplinary group (IDG) discussed bereavement issues, but stated they did not ensure the plans of care addressed bereavement. She stated they would find a way in the electronic medical record to ensure the plan of care addressed bereavement.

Based on medical record review and staff interview, the facility failed to document family involvement in the plan of care for 10 of 11 records reviewed, (#1, #2, #3, #4, #5, #6, #7, #10, #12,#13). The findings were: 1. Review of the medical record, including the plan of care, for patients #1, #2, #3, #4, #5, #6, #7, #10, #12, and #13 showed no documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care. 2. During an interview on 12/16/21 at 9:50 AM the administrator confirmed there lacked documentation to show the patients' or representatives' involvement and agreement with the plan of care.

Based on observation, staff interview and review of manufacturer instructions for use, the facility failed to ensure point of care equipment was cleaned as required for 1 of 3 random observations. The findings were: 1. Observation on 12/15/21 at 10 AM showed RN #1 used a thermometer, a stethoscope and blood pressure cuff to obtain vital signs on a patient. The RN used a sani-cloth wipe to disinfect the equipment for less than a minute and placed the equipment into a bag. The following concerns were identified: a. Interview on 12/15/21 at 10:30 AM with RN #1 revealed she was not aware the equipment needed to remain wet for 2 minutes for proper disinfection. She stated she thought the process was to wiped the equipment down, then let it air dry for 2 minutes. b. Interview with the administrator on 12/15/21 at 9:20 AM revealed she was not aware of the wet contact time instruction for proper disinfection of point of care equipment. c. Review of the Sani-Cloth wipes instructions for use showed ""To Disinfect and deodorize: Unwrap clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full 2 minutes..."

Based on medical record review and staff interview, the facility failed to develop a bereavement plan of care for 2 of 3 patients (#7, #9) who were reviewed for bereavement plans of care. The findings were: 1. Review of the medical record showed patient #7 elected hospice benefits on 10/19/21 and died on 10/31/21. Further review of the medical record showed no bereavement plan of care. On 12/16/21 at 10:54 AM the administrator confirmed there was no written bereavement plan of care for this patient's family. 2. Review of the medical record showed patient #9 elected hospice benefits on 2/12/21 and died on 6/5/21. Further review of the medical record showed although there were notes from the social worker (Master of Social Work; MSW) after the death, there was no bereavement plan of care. During an interview on 12/16/21 at 10:50 AM the administrator confirmed there was not a written bereavement plan of care. 3. During an interview on 12/16/21 at 8:50 AM the MSW stated he documents what he is doing for bereavement services in the medical record, but stated he does not develop a bereavement plan of care. He stated the electronic medical record system did not have a bereavement plan of care built in.