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Based on interview and record review the facility Dietary Manager, who routinely conducted patient nutrition assessments, failed to meet current Missouri state licensure requirements as directed by the Dietitian Practice Act. The facility census was 7 patients.

Findings included:

1. Record review of the facility policy titled Nutrition Assessment; revised 12/23/04 directed, in part, the following:
-The purpose of the policy was assess the nutritional status of patients who required an increased level of nutritional care and assure nutritionally "at risk" patients received adequate nutrition.
-The Registered Dietitian {RD} shall complete a nutritional assessment on all Swing Bed patients. In her absence the dietary manager shall perform nutrition assessments.
-The RD or in her absence the dietary manager shall complete a nutrition assessment for all tube fed patients.
-The nutrition assessment shall include a summary of the RD or dietary manager's evaluation and a care plan that identified nutritional concerns, goals and approaches.
-The RD or dietary manager shall write a progress note on the nutritional assessment form in regard to identified nutritional problems and interventions or changes in the plan of care.

2. Record review of the Missouri Revised Statutes, Chapter 324 Occupations and Professional General Provisions, Section 324.200 dated 08/28/09 directed, in part, the following:
-Paragraph 1 Commission on Accreditation for Dietetics Education (CADE), is the American Dietetic Association's accrediting agency for education programs preparing students for professions as registered dietitians.
-Paragraph 3 Dietetics practice was defined as the application of principles derived from integrating knowledge of food, nutrition, biochemistry, physiology, management, and behavioral and social science to achieve and maintain the health of people by providing nutrition assessment and nutrition care services.
-The primary function of dietary practice is the provision of nutrition care services that shall include, but not limited to: assessing nutrition care needs; establishing priorities, goals and objectives; providing nutrition education counseling; developing, implementing and managing nutrition care systems; engage in medical nutritional therapy as defined under the definition of dietetics practice.
-Paragraph 4 Dietitian is defined as one engaged in dietetic practice as defined.
-Paragraph 7 Licensed dietitian is a person licensed pursuant to the provisions of this section 324.200 through 324.225 to engage in the practice of dietetics or medical nutrition therapy.
-Paragraph 8 Medical Nutrition therapy, nutritional diagnostic, therapy, and counseling services which are furnished by a registered dietitian.
-Paragraph 9 Registered dietitian is a person who has completed a baccalaureate degree granted by an accredited college or university; completed academic requirements of a didactic program in dietetics approved by the CADE; successfully completed the registration examination for dietitians and accrued seventy-five hours of approved continuing professional units every five years; as determined by the committee on dietetic registration.

3. During an interview on 09/08/10 at 2:21 pm the Dietary Manager, Staff C stated the following:
-He/she performed patient nutrition assessment including calculation of caloric requirement and protein needs.
-When he/she was not on duty no one conducted nutrition assessments.
-He/she did not work on weekends or holidays.

During an interview on 09/10/10 at 0:02 am, the Dietary Manager, Staff C stated the following:
-The RD was a part time consultant.
-The RD worked in the facility on Mondays and Thursdays.
-The RD usually came between 8:00 am and 4:30 pm however, the dietary manager did not know the dietitian's exact hours of work.
-The dietary manager stated he/she "never knew when the RD would be in the facility".

Based on observation and interview the facility failed to ensure supplies were not expired. This had the potential to affect all patients. The census was seven.

Findings included:

1. Observation on 09/08/10 at 12:33 p.m. revealed the crash cart (a rolling cart which contains medications and supplies for emergencies) in the hall outside of the nursing station contained the following expired items:

1 - Endotracheal tube (breathing tube) Size 6.5 Lot 05HE33 Expired 07/10
1 - Endotracheal tube Size 8 Lot 05HE33 Expired 07/10
1 - Endotracheal tube Size 8 Lot 04LE10 Expired 11/09
1 - Uncuffed tracheal tube Murphy Eye Oral/Nasal Lot 1102453 Expired 08/08 (a breathing tube routinely used in young children)
1 - Uncuffed tracheal tube Murphy Eye Oral/Nasal Lot 1104197 Expired 08/08 (a breathing tube used primarily for children)
1 - Intubating Laryngeal Airway Size 2.5 Lot 020077 Expired 07/10 (an airway which uses a mask)
1 - IV Catheter 22 G 1" Expired 02/10 ( a small tube inserted into the vein to administer medications or fluids)
1 - IV Catheter 24 G 3/4" Expired 12/09
1 - IV Catheter 18 G 1.16" Expired 04/06
1 - IV Catheter 20 G 1" Expired 09/09
2 - LifePatch (Adhesive ECG Electrodes) Lot 070228 Expired 02/28/09

An interview on 09/08/10 at 12:33 p.m. revealed Chief Nursing Officer, Staff E confirmed the supplies were outdated.

An interview on 09/10/10 at 9:15 a.m. Chief Information Officer, Staff A stated the facility did not have a policy on checking and disposing of outdated supplies.

Based on observation, interview and record review facility staff failed to ensure drugs used by Respiratory department staff to treat patients were
The facility census was 7 patients.

Findings included:

1. Observation on 09/08/10 at 12:30 pm in the Respiratory Services offices revealed staff stored medications including Albuterol (used in respiratory therapy that relaxes muscles in the airways and increases air flow to the lungs) in a desk drawer in the office area.
During an interview on 09/08/10 at 12:30 pm the Supervisor, Respiratory Therapy, Staff P stated the following:
-Respiratory therapy staff obtained the multiple doses of Albuterol from the facility pharmacy as they felt it was needed to replenish the supply in the desk drawer.
-Pharmacy staff usually came in and checked the Albuterol supply.
-Respiratory staff did not have a log or any documentation showing who came from Pharmacy to check the supply or when they last checked the supply.
-Felt Respiratory staff checked the expiration dates on the medication.
-Felt Pharmacy staff checked for lot numbers of the medication.

2. During an interview on 09/09/10 at 1:55 pm the Pharmacist, Staff K stated the respiratory medications held in the Respiratory Services department were issued from the facility pharmacy and pharmacy staff did check the medications.

3. Record review of documentation (provided during the survey by the Pharmacist, Staff K) revealed the following:
-A single eight and half inch by eleven inch sheet of paper titled 2010 Pharmacy Medication monitoring with a hand written notation of "respiratory" across the top of the sheet.
-Along the left hand side a list of twelve months with illegible initials written next to month January through September.
-The single sheet of paper did not show the name of the medication, dose, total numbers of medications checked with doses of each medication or lot numbers (important for drug recalls).
-The single sheet of paper did not show the name of the Respiratory staff who obtained the medication or the Pharmacy staff who provided the medication










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Based on observation, interview and record review the facility failed to ensure the crash carts (a set of trays/drawers/shelves on wheels with medication/equipment used for life saving emergencies) were secure. The census was seven.

Findings included:

1. Observation on 9/8/10 at 11:50 a.m. revealed a crash cart in the hall outside of the nursing station with a red plastic integrity seal. The seal had no identifying number printed on it.

An interview on 9/8/10 at 12:33 p.m. Registered Nurse (RN) F stated a few integrity seals were left on the unit in case the cart was opened and the seal needed to be replaced and there was no tracking of the seals.

2. Observation on 9/8/10 at 2:15 p.m. revealed a drug cart in the Emergency Department nursing station and the drawers were not locked except for the drawer containing the narcotics. The contents of the drawers in part included Syrup of Ipecac ( a drug used to induce vomiting) , Ancef (an antibiotic), Tigan (a medication used to treat nausea and vomiting) injectable, Flagyl (an antibiotic), Tylenol ( a drug used to treat pain and/or fever).

An interview on 9/8/10 at 2:25 p.m. Supervisor of ED G stated the drawers had been broken for months and a work order had been placed but the drawers had not been repaired. He/she stated the cart was not always under the direct supervision of staff.

3. Record review of the facility policy titled Acute Nursing, Emergency Department, Outpatient Surgery/Ambulatory Care reviewed 09/09 in part stated the following;

Purpose: To provide guidelines for nursing staff when checking and supplying the crash cart. . .

Procedures:
6. Pharmacy will check and restock the crash carts every morning Monday-Friday, and after each use. They will lock drawers after they are stocked.

Based on observation, interview and record review facility Infection Control staff failed to develop and maintain a facility wide program for identification, reporting, investigation and control of infections and communicable disease for patients, staff and volunteers. Facility Infection Control staff also failed to provide an effective infection control education program to all staff and volunteers in all departments working all shifts. The facility census was 7 patients.

Findings included:

1. Observation on 09/08/10 in the Rehabilitation Services gym revealed staff stored soiled linen in an uncovered linen receptacle.

During an interview on 09/08/10 at 11:48 am the Director of Rehabilitation Services stated staff usually covers the soiled linen receptacle and just failed to do so today.

2. Observation on 09/08/10 at 12:35 pm in the Respiratory Services clean supply room revealed the following:
-Staff stored clear plastic bins of individually packaged patient supplies on wire shelving.
-Staff also stored two opened, briefcase like binders packed with papers and non-departmental reading material next to the bins on the same shelving.
-Both briefcases were opened and fully unzipped.
-Staff stored an unzipped suitcase packed with clothing and personal items including a brown prescription vial protruding from the suitcase contents.

During an interview on 09/08/10 at 12:35 pm the Director of Respiratory Services, Staff B stated the suitcase of personal items and the two briefcases on shelving stored next to the bins of patient care supplies was "nothing" since it was personal reading material that belonged to staff who stay overnight.

3. Review of the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, directed, in part the following:
-Chapter 2-402.11 Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, and that are designed and worn to effectively keep hair from contacting exposed food, clean equipment and utensils.
-Chapter 3-304.11 Food shall only contact surfaces of equipment and utensils that are cleaned.
-Chapter 3-304.12 Food dispensing utensils shall be stored with the handles above the surface of the food.
-Chapter 3-305.11 Food shall be protected from contamination by storing in a clean, dry location and not exposed to splash, dust or other contamination.

Record review of the facility Dietary department policy and procedure titled Food Safety and Sanitation; revised 2010 directed, in part, the following:
-Mustaches, beards and sideburns are to be neatly trimmed, clean and covered.
-Hair restraints are required and should cover all hair on the head.
-Foods are protected from contamination (dust, flies, rodents, and other vermin).
-Foods stored in the storeroom are placed on clean racks.
-Foods with expiration dates are used prior to the date on the package.
-Dry storage areas will be kept in a condition which protects stored foods from infestation.
-All items must be stored at least six inches off the floor.
-Shelves {in the dry storage area} are kept clean.
-Floors must be swept clean at all times and mopped at least weekly.

Observation on -9/08/10 from 2:05 pm through 2:49 pm revealed the following:
-Staff stored dry taco seasoning powder in a four quart container with the paper label embedded into the surface of the food.
-Staff stored cans and boxes of dry foods on food splashed and unknown debris ladened, heavily soiled wire shelving in the dry food storeroom.
-Staff stored dry corn meal containers on a shelf with an approximate two inch cone shaped pile of unknown debris on the floor below.
-Staff stored a plastic container labeled baking mix with a measuring cup imbedded into the surface of the food.
-Staff stored a plastic bag of carrots on the floor of the walk-in refrigerator.
-Staff stored an expired {dated 09/03/10} one quart container of buttermilk on a shelf in the walk-in refrigerator.
-Staff stored a partial case of raw eggs in the shell on a shelf above a bag of carrots.
-Staff stored a fuzzy, cloth stuffed animal on a shelf where partial packages of foods and condiments were also stored.

During an interview on 09/08/10 at 2:05 pm the Dietary Manager, Staff C stated the following:
-Staff stored the taco seasoning powder label inside the container so they could save the preparation directions.
-Staff should be cleaning the wire shelving in the dry foods storeroom once a month.

Observation on 09/09/10 at 11:05 am revealed the Registered Dietitian entered the kitchen walked through the dish washing area where staff stored cleaned dishes, past the cook's area where staff was preparing bread dressing and failed to wear an effective hair restraint.

Observation on 09/09/10 at 11:40 am revealed a dietary staff person failed to cover facial hair while working in the food storage areas putting cases of foods in refrigeration and dry storage.

Observation on 09/09/10 at 11:45 am revealed a food delivery person entered the dietary department multiple times and staff failed to request the delivery person to don effective hair restraint.

During an interview on 09/09/10 at 11:45 am when asked if all persons entering the kitchen were asked to don hair restraints, the Dietary Manager, Staff C stated, "I'm new at this job."

4. During an interview on 09/10/10 from 8:25 am through 9:10 am, the Infection Control Nurse (ICN), Staff O stated the following:
-He/she had been in position since approximately 1994.
-Conducted surveillance of patient related infections by reviewing the lab culture reports, the outpatient logs and the Emergency Department logs for any patients who had been seen for an infection.
-Agreed that this method of reviewing logs for infections was after the fact review.
-He/she reviewed the lab culture reports for MRSA {methicillin resistant staph aureus, antibiotic resistant bacteria}.
-He/she reviewed the patient medical records however, this too was after the fact and not while the patient was still in-house.
-Obtaining lab results may take a few days especially if the specimen were sent to an offsite laboratory.
-If he/she found anything that needed follow up, he/she usually called the local health department and reported the issue.
-A physician affiliated with the offsite laboratory reviewed the Infection Control Log that was maintained by the ICN, Staff O.
-The facility did have an Infection Control Committee that was open to all departments, with meetings held monthly however, usually the only attendees were the ICN, Staff O and the physician affiliated with the offsite laboratory.
-Facility staff were provided Infection Control education by annually viewing the computer Care Learning program and no department specific infection control education was offered by the ICN, Staff O.
-Each facility department had policies and procedures reviewed by the physician member of the Infection Control Committee however, the ICN, Staff O did not review them.
-The ICN, Staff O worked Monday through Friday from 8:00 am through 4:30 pm, no weekends and no holidays.
-Monitoring of facility staff infection control practices consisted of watching the day shift only, not any staff after 4:30 pm and no staff on weekends or holidays.
-No formalized monitoring schedule was in effect using specific study parameters or review of specific departmental staff because "we're a small hospital".
-Isolation methods and adherence to facility isolation policies and procedures were not monitored because "we don't have many, maybe one or two a month".
-Did not know if staff on night shift or on weekends or holidays were using appropriate measures for protection against cross contamination in isolation patient rooms.
-Some staff on off-shifts may not be using the personal protective equipment (PPE, disposable gowns, masks, gloves) appropriately.
-Facility cleaning agents and disinfectants were approved by the physician affiliated with the offsite laboratory and not the ICN, Staff O who was on site.
-He/she did not perform any specific infection control Quality Assurance monitoring or document any studies.
-He/she maintained an Infection Control Log by writing down a patient identifier and the infective organism however did not record antibiotic used or any treatment used because "we don't have that many".
-Was unaware that an Infection Control log was necessary until informed by surveyors on a previous survey and to date was only on page two of the log.
-Monitored surgical site infections from what was written in the outpatient logs however agreed there may be others that were not treated in the outpatient clinic.
-Was not aware of any facility employees who worked while they were ill but did not see every employee especially those working night, weekends or holidays.

Based on observation, interview and record review facility Dietary department staff failed to store foods appropriately to protect against cross contamination, failed to clean and maintain floors and shelving in the dry food storage room in a sanitary manner and failed to ensure effective hair restraints were worn in the facility kitchen to protect against cross contamination of foods and cleaned surfaces. The facility census was 7 patients.

Findings included:

1. Review of the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, directed, in part the following:
-Chapter 2-402.11 Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, and that are designed and worn to effectively keep hair from contacting exposed food, clean equipment and utensils.
-Chapter 3-304.11 Food shall only contact surfaces of equipment and utensils that are cleaned.
-Chapter 3-304.12 Food dispensing utensils shall be stored with the handles above the surface of the food.
-Chapter 3-305.11 Food shall be protected from contamination by storing in a clean, dry location and not exposed to splash, dust or other contamination.

Record review of the facility Dietary department policy and procedure titled Food Safety and Sanitation; revised 2010 directed, in part, the following:
-Mustaches, beards and sideburns are to be neatly trimmed, clean and covered.
-Hair restraints are required and should cover all hair on the head.
-Foods are protected from contamination (dust, flies, rodents, and other vermin).
-Foods stored in the storeroom are placed on clean racks.
-Foods with expiration dates are used prior to the date on the package.
-Dry storage areas will be kept in a condition which protects stored foods from infestation.
-All items must be stored at least six inches off the floor.
-Shelves {in the dry storage area} are kept clean.
-Floors must be swept clean at all times and mopped at least weekly.

2. Observation on -9/08/10 from 2:05 pm through 2:49 pm revealed the following:
-Staff stored dry taco seasoning powder in a four quart container with the paper label embedded into the surface of the food.
-Staff stored cans and boxes of dry foods on food splashed and unknown debris ladened, heavily soiled wire shelving in the dry food storeroom.
-Staff stored dry corn meal containers on a shelf with an approximate two inch cone shaped pile of unknown debris on the floor below.
-Staff stored a plastic container labeled baking mix with a measuring cup imbedded into the surface of the food.
-Staff stored a plastic bag of carrots on the floor of the walk-in refrigerator.
-Staff stored an expired {dated 09/03/10} one quart container of buttermilk on a shelf in the walk-in refrigerator.
-Staff stored a partial case of raw eggs in the shell on a shelf above a bag of carrots.
-Staff stored a fuzzy, cloth stuffed animal on a shelf where partial packages of foods and condiments were also stored.

During an interview on 09/08/10 at 2:05 pm the Dietary Manager, Staff C stated the following:
-Staff stored the taco seasoning powder label inside the container so they could save the preparation directions.
-Staff should be cleaning the wire shelving in the dry foods storeroom once a month.

3. Observation on 09/09/10 at 11:05 am revealed the Registered Dietitian entered the kitchen walked through the dish washing area where staff stored cleaned dishes, past the cook's area where staff was preparing bread dressing and failed to wear an effective hair restraint.

Observation on 09/09/10 at 11:40 am revealed a dietary staff person failed to cover facial hair while working in the food storage areas putting cases of foods in refrigeration and dry storage.

Observation on 09/09/10 at 11:45 am revealed a food delivery person entered the dietary department multiple times and staff failed to request the delivery person to don effective hair restraint.

During an interview on 09/09/10 at 11:45 am when asked if all persons entering the kitchen were asked to don hair restraints, the Dietary Manager, Staff C stated, "I'm new at this job."

Based on record review and policy review the facility failed to ensure the Medical staff followed the facility policy on authenticating verbal and telephone orders by not
signing, dating and/or timing orders of six of six in-patients (Patient #4, #7, #14, #16, #17 and #18). The facilities census was seven on 09/08/10.

Findings included:

-Record review of the facility policy titled Writing Physician Orders reviewed 09/09 revealed in part the following information:

PURPOSE: To establish uniform guidelines in the receiving and recording of medication orders:

GUIDELINES:
SUPERVISION BY A PHYSICIAN
2. Physician's orders must be signed by the physician as well as the time and date when each order was written.
RECORDING ORDERS
10. Telephone/Verbal Orders:
e. Telephone or verbal orders must be countersigned, timed and dated by the physician within 24 hours Acute Nursing. . .

1. Record review of Patient #4's medical record revealed the following information:
-The telephone order of 09/8/10 at 12:12 a.m. was not authenticated by the physician with signature, date or time.
-The verbal order on 09/8/10 at 8:00 a.m. was not authenticated by the physician with the date or time.
- The verbal order on 09/8/10 at 10:45 a.m. was not authenticated by the physician with the date or time.
- The verbal order on 09/8/10 at 1:30 p.m. was not authenticated by the physician with the signature, date or time.

2. Record review of Patient #7's medical record revealed the following information:
-The verbal order on 08/30/10 at (no time) was not authenticated by the physician with the date or time.
-The telephone order of 08/31/10 at 2:15 p.m. was not authenticated by the physician with signature, date or time.
-The verbal order on 09/2/10 at 1:30 a.m. was not authenticated by the physician with the signature, date or time.
-The order (no documentation as to verbal or telephone) on 9/4/10 (no time) was not authenticated by the physician with a date or time.

3. Record review of Patient #14's medical record revealed the following information:
-The verbal order on 09/3/10 at 1:30 p.m. was not authenticated by the physician with the signature, date or time.
-The telephone order on 09/3/10 at 5:30 p.m. was not authenticated by the physician with the date or time.
-The telephone order on 09/4/10 at 7:25 p.m. was not authenticated by the physician with the date or time.
-The telephone order on 09/710 at 5:45 p.m. and 9/8/10 at 1:00 p.m. and 9/8/10 at 3:00 p.m. was not authenticated by the physician with the signature, date or time.

4. Record review of Patient #15's medical record revealed the following information:
-The telephone order on 09/6/10 (no time) was not authenticated by the physician with the signature, date or time.

5. Record review of Patient #16's medical record revealed the following information:
-The telephone order on 09/6/10 (no time) was not authenticated by the physician with the signature, date or time.
-The telephone order on 9/7/10 at 12:15 a.m. was not authenticated by the physician with the signature, date or time.

6. Record review of Patient #18's medical record revealed the following information:
-The telephone order on 09/8/10 at 10:45 a.m. was not authenticated by the physician with the date or time.
-The verbal order on 09/8/10 at 11:30 a.m. was not authenticated by the physician with the signature, date or time.

Based on interview and record review the facility failed to ensure the staff follow the facility policy when comprehensive, individualized, updated care plans were not provided for five (Patients #4, #7, #14, #15, #16) of six in patients. The census was seven.

Findings included:

1. Record review of Patient #4's medical chart revealed the patient was admitted to the facility on 09/07/10 for acute diverticulitis (a disease which causes infected small pockets in the colon).

Record review of the Gastrointestinal Nursing Care Plan initiated 09/07/10 at 11:50 p.m. revealed no updating of the care plan since initiation and nothing that was specific to the patient.

2. Record review of Patient #7's medical chart revealed the patient was admitted to the facility on 08/30/10 for care related to left knee arthroplasty on 08/27/10.

Record review of the Nursing Care Plan initiated 08/30/10 at revealed no updating of the care plan since initiation.

3. Record review of Patient #14's medical chart revealed the patient was admitted to the facility on 09/06/10 for continued treat for right hemiplegia/CVA (stroke with right sided weakness, and weakness.

Record review of the Neurological Nursing Care Plan initiated 08/31/10 revealed no updating of the care plan since initiation.

4. Record review of Patient #15's medical chart revealed the patient was admitted to the facility on 08/26/10 for pain control and emotional and physical rehabilitation after a fracture of the right hip and right wrist.

Record review of the Nursing Care Plan initiated 08/26/10 revealed no updating of the care plan since initiation.

5. Record review of Patient #16's medical chart revealed the patient was admitted to the facility on 09/06/10 for care after a right total hip replacement on 09/01/10.

Record review of the Nursing Care Plan initiated 09/06/10 revealed no updating of the care since initiation on 09/06/10.

Record review of the Nursing Care Plan initiated 9/6/10 revealed no updating of the care since initiation on 08/26/10.

-An interview on 09/10/10 at 9:15 a.m. CIO A stated the care plans were not updated as needed or as the policy stated.

-Record review of the facility policy titled Nursing Care Plan reviewed 09/00 in part revealed the following information:

PURPOSE: To establish a uniform guide for establishing individualized patient nursing care plans.

POLICY:

C. The plan is updated and revised Periodically based on evaluation of patient progress/achievement of goals.

PROCEDURES:

C. 8. When using standardized care plans they will be individualized for each patient.
11. Each nurse admitting and reviewing should sign and date the care plan each time care plan is updated.

Based on observation, interview and record review facility staff failed to protect paper patient medical records against destruction by fire. The facility census was 7 patients.

Findings included:

1. Observation on 09/08/10 at 4:20 pm revealed Health Information Management (HIM) staff stored paper patient medical records on floor to ceiling shelving in two separate unlocked rooms (converted from patient care rooms to storage). Further observation revealed neither room had fire suppression, smoke detectors or heat sensors mounted in the room.

Observation on 09/08/10 at 4:26 pm revealed the following:
-HIM staff stored paper patient medical records on approximately eight foot tall shelving in a garage.
-The garage was separated from the main hospital.
-The garage also housed a gasoline powered riding lawn mower, a pick-up truck and two other gasoline powered lawn tractors.
-The odor of gasoline was detectable on entry into the garage.
-Much of the shelving that held the paper medical records consisted out bare wood boards.
-The garage also housed an upper level, accessible via an open wooden staircase, where HIM staff stored more paper medical records.
-Staff stored two or three large therapeutic gas tanks stored under the staircase along with five red oxygen tanks.
-Other debris and unknown parts of various types of equipment were stored throughout the structure next to and/or near the paper medical records.

2. During an interview on 09/08/10 at 4:26 pm the Supervisor of HIM, Staff D stated few staff entered the garage and the only staff who would routinely access the area were Maintenance staff.

During an interview on 09/09/10 at 8:32 am, the Supervisor of HIM, Staff D and the Chief Information Officer, Staff A both stated the facility failed to establish a policy and procedure for protection of paper patient medical records against destruction by fire.

Based on interview and record review facility Activities staff failed to provide each Swing Bed resident (Residents #7, #14, #15, #16) with an ongoing activities program planned to meet individual needs in accordance with a comprehensive assessment that encompassed interests, physical, mental and psycho-social well-being of the resident. The facility census was 7 patients with 4 of those being Swing Bed residents.

Findings included:

1. Record review of the facility admissions packet documents revealed an informational handout titled Patient'/Resident' Conduct and Responsibilities Acute/Swing Bed/ ICP {Intermediate Care Program}, Conduct and Responsibilities which directed under the paragraph titled Activities, Socialization is part of Rehabilitation. Patients/Residents are encouraged to participate in selected Activities.

2. Record review of current Swing Bed Resident #7's Resident Profile and Activities Program Information form revealed the Activities Director (AD), Staff N assessed the resident with the following:
-Was admitted on 08/30/10 with diagnosis of recent left knee replacement.
-Was Baptist, had visitors consisting of family.
-Required eyeglasses and a walker for ambulation.
-Was alert and oriented to person, place and time however some confusion had on admission and at night.
-Had interests including TV {television} however did not document if this was past or a present interest or offer any alternative activities in lieu of television.
-Requested activity programs of "TV only".
-The AD summarized the resident liked television with local news and radio access but failed to document how the resident would access the radio and failed to offer other activities when the local news was not being televised.
-The AD assessed the family was at the bedside and the Baptist church was aware of the resident's admission to the facility but failed to document a plan for facilitation of visits by the Baptist church members.
-The AD Assessed the facility Chaplain would visit however failed to document when and how many times the Chaplain would visit.
-The AD set a goal of maintain psychosocial well being through participation with activities of interest however failed to document specific interventions by the AD ensuring how the immeasurable goal would be met.

3. Record review of current Swing Bed Resident #14's Resident Profile and Activities Program Information form dated 09/09/10 revealed the AD, Staff N assessed the resident with the following:
-The resident was admitted on 09/03/10 {six days prior to the assessment} with right sided paralysis, recent stroke, and weakness and medical history of chronic obstructive pulmonary disease.
-Required eyeglasses and a walker to ambulate.
-Was alert and oriented to person, place and time.
-Had interests including knitting, word puzzles and television for noise.
-Declined an offer of word puzzles due to not feeling well and no interest in usual activities.
-The AD documented a plan to continue follow up with the resident regarding activities of interest (knitting, word puzzles and television for noise) and failed to offer alternative activities or plans to engage the resident in other activities (like one to one conversation regarding knitting, knitting projects, videos on knitting, other crafts).
-The AD failed to document if the resident had eyeglasses at the facility and failed to assess if the resident's stroke and right sided paralysis impaired the ability to perform the desired activities.
-The AD set a goal of patient to participate in at least three activities per week however failed to document a plan to offer any activities at all.

4. Record review of current Swing Bed Resident #15's admission history and physical dated 08/26/10 revealed the physician assessed the resident with a need for pain control and requirements for emotional and physical rehabilitation. The resident's physician further assessed the resident had medical problems including recent surgical repair of a right hip fracture and a right wrist fracture, heart problems and high blood pressure.

Resident Profile and Activities Program Information form revealed the AD, Staff N assessed the resident with the following:
-Was alert and oriented with "short term memory".
-Was right handed.
-Was hard of hearing.
-Had interests in sewing, crocheting, card games, religious television, reading the Bible.
-The AD assessed the resident was discouraged due to the fractures however failed to plan any interventions addressing this emotional state.
-The AD set a goal of maintain participation with room visits and activities on interest at least three times a week however failed to plan any sewing or crocheting related interventions (videos, one to one discussion with a volunteer who sews, craft books) for the resident with recent wrist fracture.
-The AD also failed to plan activity interventions addressing the resident's hearing impairment (head phones for the television, religious tapes or audio Bible).
-The AD inferred the resident had a memory problem but failed to plan and implement activities involving reality orientation and cueing.

5. Record review of current Swing Bed Resident #16's Resident Profile and Activities Program Information form revealed the AD, Staff N assessed the resident with the following:
- Was admitted on 09/06/10 with diagnoses of recent right total hip replacement.
-Was blind in the right eye.
-Required a walker for ambulation.
-Was alert and oriented to person, place and time.
-The AD failed to assess for any past or present interests.
-The AD documented a plan for room visits twice a week but failed to document activities that would take place twice a week during the room visits.
-The AD set a goal of the resident would participate twice a week but failed to document and plan specific interventions that would occur twice a week.

6. During an interview on 09/09/10 at approximately 2:00 pm, the Activities Director, Staff N stated the following:
-He/she was a Licensed Clinical Social Worker and by default the Activities Director (AD).
-As the AD, he/she would meet with any newly admitted Swing Bed resident to find out what activities the resident enjoyed prior to admission.
-He/she did not have a pre-planned Activity calendar.
-He/she usually just planned one to one activities per the resident's interests.
-The facility did not have an activities room.
-The Activities program did not have a budget purchase supplies and equipment.
-The facility had a cabinet at the end of the nurse station hallway where the AD stored games, word search books and cards.
-The facility owned a DVD player however most of the videos were on VHS.
-He/she worked Monday through Friday from 8:00 am to 4:30 pm and felt after 4:30 pm and weekends were family time.
-He/she did not work on holidays so there were no planned activities for Christmas, Thanksgiving, Easter or other holidays.
-The facility did not give Swing Bed residents gifts.
-A Swing Bed resident could be alone on Christmas day
-On holidays, the activities available were word puzzle books.
-He/she usually left the activities program up to the nursing staff on holidays.