Idaho Falls Community Hospital, LLC

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 51906 Based on observation, facility policy review, and staff interview, it was deterred the hospital failed to provide a sanitary environment and follow infection control measures to avoid transmission of potential infection. Failure to ensure proper infection control processes has the potential to impact the health of patients and staff. Findings include: 1. Refer to tag A - 750 as it relates to failure of the facility to ensure that all staff are following infection prevention and control policies and procedures and infection control measures in the hospital during patient care and interaction.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 39430 Based on observation, interview, and policy review, the facility failed to ensure staff maintained a clean and sanitary environment to limit the potential transmission of infection. These failures directly affected 5 of 5 Patients (#7, #8, #9, #11 and Patient #12) whose care was observed. This had the potential for infections to be transmitted throughout the hospital and potentially affect all patients and staff in the hospital. Findings include: The hospital policy titled “IV therapy - Peripheral IV Line,” dated 10/24 included under the section titled “Procedure: ...13. Maintain the sterility of the male leur end of the administration set before and during connection to the IV hub .... 16. Perform a vigorous mechanical scrub of the needleless connector of the primary line that’s closest to the primary solution bag for at least 15 seconds with an antiseptic pad and allow it to dry completely.” Additionally, under the section titled “Administering an IV push medication,” it stated: “8. Perform a vigorous mechanical scrub of the needleless connector for at least 15 seconds and let it dry completely.” This policy was not followed. The hospital had a policy titled, “Hand Hygiene - Policy and Procedure per CDC Guidelines” with a last approved date of 10/24. The policy stated, “In accordance ...IFCH’s infection prevention and control program requires all staff to use the approved hand-hygiene techniques... 3. Before each patient encounter ... 6. After coming in contact with patient intact skin ... 10. After contact with medical equipment/supplies in a patient’s area. ... 11. Always after removing gloves.” The hospital had a policy titled “Employee Dress and Appearance Policy” with a last approved date of 3/2025. The policy stated, “Employees conducting business in an area that treats, touches, or interacts with patients should wear close-toed shoes at all times.” These policies were not followed. Examples include: 1. Patient #8 was a 58 year old female admitted to the hospital on 7/31/25 at 12:31 AM with admission reason listed as “AMS.” An ICU RN’s care for Patient #8 was observed on 8/05/25 beginning at 10:15 AM. The RN was observed to go into Patient #8’s room and assist patient to the bathroom. The RN was observed to throw away soiled chucks from the patient’s bed while wearing gloves. The RN was then observed administering an IV medication to Patient #8. The RN did not perform hand hygiene and change gloves prior to administering medications to Patient #8’s IV line. 2. Patient #7 was an 82 year old male admitted to the hospital ICU on 8/03/25 at 8:46 PM with admission reason listed “urine problem.” An ICU RN’s care for Patient #7 was observed on 8/05/25 beginning at 10:00 AM. The following breaches in infection control were observed. - The RN was observed to not use hand hygiene prior to touching the patient. - The RN was further observed to not perform hand hygiene prior to donning clean gloves. - The RN was observed to not clean the top of the vial of medication before drawing up the dose and then observed to not clean/alcohol swab the IV port before administering medication. The RN was interviewed on 8/05/25 beginning at 11:30 AM. The RN was asked if he cleaned the vial before drawing up the medication or before administering the medication into the patient’s IV line. The nurse reported he “didn’t recall.” When asked if cleaning the vial and IV port were normal expected duties prior to administering medication the nurse stated “6s.” When asked what he meant the nurse reported “6 of one half a dozen of the other.” When asked what is meant by that statement the nurse said it meant sometimes he does it. 3. A cardiologist was observed on 8/5/25 beginning at 10:35 AM in Patient #7’s room. The cardiologist was observed to apply hand hygiene foam to one but not both hands while walking into patient room. Cardiologist was observed to lift the bedsheet of Patient #7 with her non-foamed hand and touch the patient with the other. The cardiologist was also observed to be wearing sandals. The sandals were slotted and open on the sides and top. The cardiologist was observed to touch and lift the catheter bag with a sandaled foot and then leave the room without further hand hygiene or other infection control practices. 4. Patient #9 was a 74 year old male admitted to the hospital medical - surgical unit on 8/04/25 with admission reason listed “weakness.” On 8/05/2025 at 9:45 AM, an RN was observed providing care to Patient #9. During medication administration, Foley catheter adjustment, and bedside documentation, the nurse changed gloves on three occasions without performing hand hygiene between glove changes. During the same observation Patient #9’s RN was noted to have supplies (e.g., saline syringes, IV port caps) stored loosely in her uniform pocket. After performing cares for Patient #9, while wearing gloves, she retrieved a sterile IV port cap from her pocket and used it for Patient #9. She exited the room with the remaining supplies still in her pocket, potentially contaminated. Patient #9’s RN was interviewed on 08/05/25 beginning at 10:15 AM after the observations. She confirmed she should have performed hand hygiene after glove removal. The Medical Surgical unit manager was interviewed on 8/05/25 beginning 1:00 PM and the above observations were reviewed with her. She confirmed all staff should perform hand hygiene after glove changes. Additionally, she stated clean supplies should not be accessed without hand hygiene prior. 5. Patient #12 was an 80 year old male admitted to the hospital stepdown unit 8/02/25 for influenza. His care was observed between the stepdown unit and the medical -surgical unit. On 8/05/2025 at 10:30 AM, the CNA caring for Patient #12 was observed. Patient #12 was on droplet precautions for influenza. The CNA donned appropriate PPE (gown, mask, gloves) and performed tasks including repositioning the patient and arranging belongings. While still wearing gloves, he retrieved a cell phone from his pocket, answered a call, and returned the phone to his pocket without removing gloves or sanitizing the device. The stepdown unit manager was interviewed on 8/05/25 beginning at 2:00 PM and the above observations were reviewed with her. She stated usage of interdepartmental phones for communication being used in the patient rooms had posed a problem. She confirmed the phone should be either cleaned after usage or hand hygiene performed before and after usage of the phone. 6. Patient #13 was a 68 year old male who was admitted to the ICU on 8/04/25. On 8/05/25 beginning at 3:15 PM, the care team which included 3 RN’s, a CNA, an RT, and a CRNA for Patient #13 were observed. The CRNA was observed touching the computer keyboard and then touching the patient, specifically the patient’s ET tube, without changing gloves or performing hand hygiene. The CRNA was observed pulling an unpackaged uncapped syringe out of her pocket and administering IV medication to the patient. The CRNA did not clean the IV needleless connector before administering the medication. The RT was observed with gloved hands touching bags that were hanging from the IV pole and pulling out various pieces of equipment and then touching the patient’s ET tube without changing gloves or performing hand hygiene. At 3:36 PM an RN was observed administering medication to the patient’s IV needleless connector. The RN did not clean the connector before attaching a syringe to the connector and injecting the medication to the patient’s IV line. The facility failed to ensure policies and procedures for infection control were followed.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 42316 Based on ED log review, medical record review, policy review, and staff interview, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in the failure to provide an appropriate and complete MSE to a patient. Findings include: Refer to A2406 as it relates to the failure of the hospital to ensure all patients presenting to the hospital for emergency services were provided an MSE. Failure to ensure all patients presenting to the ED were provided with an appropriate and complete MSE had the potential to negatively affect all patients presenting to the ED.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42316 Based on ED log review, medical record review, policy review, and staff interview, it was determined the hospital failed to ensure an appropriate MSE was conducted for 1 of 4 patients (Patient #8) who’s disposition was documented AMA and whose records were reviewed. Failure to conduct a complete MSE had the potential for significant problems to go untreated. Findings include: A facility policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines,” revised March 2025 stated, “Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not ... the purpose of the medical screening is to determine if an emergency medical condition exists so that EMTALA is covered.” The ED log was reviewed. It showed Patient #8 presented to the ED on 6/26/25. There was no chief complaint listed. It stated Patient #8 left without being seen. Patient #8’s medical record was reviewed. It included an “Admit-Discharge-Transfer Form,” discharge documentation stating Patient #8 left the ED AMA, and a “Refusal of Screening Exam, Treatment, and/or Transfer” form signed by Patient #8. At the time of survey exit, there was no physician note documented in Patient #8’s medical record. Patient #8’s record included an “Admit-Discharge-Transfer Form,” which stated, “ED Disposition : Left without being seen ... Reason For Leaving: Other: PT [patient] presented to ed with numbness and tingling in all extremities [sic]. [name of office of provider] provider was concerned for a blood clot after thoracic outlet release, [Physician A] at the bedside and was not concerned of a clot, pt then did not want treatment at this time ... ED Physician Notified: [Physician A] ... Comments : Refusal of screening exam paper work completed.” Patient #8 was contacted but did not return a phone call. The RN who documented the above note was unavailable for interview. Physician A was unavailable for interview during the EMTALA survey. Physician A was interviewed by phone on 8/8/25, after the survey exit, beginning at 10:41 AM. When asked if he assessed Patient #8 he said, “I did not.” He stated she had tingling in her hands and feet and a clot was unlikely based on just that. He stated he didn’t see her but spoke to her at the bedside. He stated Patient #8 determined she did not want to be there and requested to be seen by her PCP. He stated, “If they check in and do the whole visit they have to pay for it,” so he requested the visit be cancelled but did not realize the nurse put a note in. During the interview with Physician A, he stated, he placed a note in Patient #8’s chart. The note was requested and received on 8/08/25 11:04 AM. The note was signed on 8/06/25 at 9:21 PM, after the survey exit. It stated, “The patient is a 44 yo [year old] female who initially presented to the ED by recommendation of a medical provider at her work. After talking with her family before my arrival into the room, patient had decided to not be seen and follow up routinely with her primary medical provider. She is complaining of “tingling” sensations in her extremities without localizing neurological concerns or weakness. After a brief discussion about her symptoms, I did encourage her to stay and see if we can determine the cause of her initial concerns. However, the patient has politely refused a medical screening examination or any further work-up at this time. She does understand the potential of possible serious, undiagnosed medical issues if she leaves prior to evaluation. I did offer again to evaluate her and make treatment recommendations based on her initial concerns. However, she felt that her symptoms were not severe and did not require emergent evaluation or treatment. The patient was invited to return to the emergency department at any time if she changes her mind. No ER Physician charge for this patient as she decided to leave prior to examination or any treatment.” It was unclear how Physician A determined a clot was unlikely if he did not assess Patient #8. The hospital failed to ensure all patients presenting to the ED were provided a complete MSE.”