HospitalInspections.org

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to maintain accountability for the CAH's maintenance and housekeeping procedures.

Findings included:

- The CAH failed to assure all equipment is maintained for safe operating condition as evidenced by C222; CFR 485.623(b)(1).

- The CAH failed to assure the premises are clean and orderly as evidenced by C225; CFR 485.623(c)(4).

- The CAH failed to develop and implement a plan for emergency fuel for the diesel powered generator and emergency water supply as evidenced by C229; CFR 485.623(c)(3).

- The CAH failed to assure the safety of patients in non-medical emergencies as evidenced by C230; CFR 485.623(c)(4).

The Critical Access Hospital (CAH) reported an average daily census of eight patients. Based on observation and interview, the CAH failed to ensure the housekeeping and maintenance programs maintained all equipment affecting patient care in a safe manner.


Findings included:

- Observation in the laundry area on 4/27/10 at 9:30am revealed the floor with worn gray paint and exposed concrete in many areas. Interview with staff E on 4/29/10 at 12:05pm confirmed the concrete lacked sealant and is a porous, non-cleanable surface.

- Observation in the laundry area on 4/27/10 at 9:30am revealed a folding table with exposed wooden edges. Staff H, at that time, confirmed the table is porous, non-cleanable surface.

- Observation of the patient care hallway on 4/27/10 at 10:45am revealed bugs in each patient room's call light covers and the hallways fluorescent light covers. Staff H, at that time, confirmed the presence of the dead bugs and lacked knowledge of when the light covers were last cleaned.

- The door to the solarium, observed on 4/27/10 at 10:30am revealed three 1 inch by 2 inch areas of deep gouges and rough and non-cleanable surface in the wooden door. Staff H, at that time, confirmed the presence of the non-cleanable surfaces.

- Observation 4/27/10 at 10:45am in the storage area near the conference room revealed a blanket warmer and other patient care supplies in the room. The entire ceiling of the approximately 8 foot by 8 foot room was peeling and/or blistered.
Administrative staff A, interviewed on 4/29/10 at 1:00pm confirmed the storage of patient care supplies in the room with the blistered and peeling ceiling.

The Critical Access Hospital (CAH) reported an average daily census of eight patients. Based on observation and interview, the CAH failed to assure the CAH premises are clean and orderly.


Findings included:

- Observation in the laundry area on 4/27/10 at 9:30am revealed the floor with worn, gray paint and exposed concrete in many areas. Interview with staff E, on 4/29/10 at 12:05pm, confirmed the concrete lacked sealant and is a porous, non-cleanable surface.

- Observation in the laundry area on 4/27/10 at 9:30am revealed a folding table with exposed wood around the table's edge. Staff H, at that time, confirmed the porous, non-cleanable surface.

- Observation of the patient care hallway on 4/27/10 at 10:45am revealed dead bugs in each patient room's call light covers and the hallway fluorescent light covers. Staff H, at that time, confirmed the presence of the dead bugs and lacked knowledge of when the light covers were last cleaned.

- Observed on 4/27/10 at 10:30am of the south hallway solarium revealed three- 1 inch by 2 inch areas of deep gouges and rough and non-cleanable surface in the wooden door. Staff H, at that time, confirmed the presence of the non-cleanable surfaces.

- Observation of the storage area near the conference room on 4/29/10 at 1:00pm, revealed a blanket warmer and other patient care supplies in the room. The entire ceiling of the room, approximately 8 foot by 8 foot was peeling and blistered. Administrative staff A, interviewed at that time, confirmed the storage of patient care supplies in the room with the blistered and peeling ceiling.

- Observation of the radiology suite on 4/27/10 between 2:35pm and 3:00pm revealed a pad for the radiology table with a cloth cover placed directly on the floor. Staff I confirmed the pad is placed on the table for patient use when needed without disinfection.

The Critical Access Hospital (CAH) reported an average daily census of eight patients. Based on observation, interview and lack of documents for review, the CAH failed to develop and implement a plan for emergency fuel for the diesel powered generator and emergency water supply.

Findings included:

- Observation of the CAH on 4/27/10 at 9:30am revealed a diesel-powered generator for the emergency electrical supply. Staff H, interview on 4/27/10 at 9:30am stated the CAH obtained fuel from a local vendor, but lacked a verbal agreement or written contract with the vendor.

- Observation of the CAH on 4/27/10 between 9:30am and 12:00pm revealed the lack of stored potable water in cases of a disruption in the usual water supply to the CAH. Staff H, interviewed on 4/27/10 at 12:00pm, acknowledged the CAH lacked an emergency supply of potable water. Staff H further acknowledge the CAH lacked an agreement or contract with a vendor for the provision of emergency potable drinking water.

The Critical Access Hospital (CAH) reported an average daily census of eight patients. Based on interview and the lack of documentation to review, the CAH failed to assure the safety of patients in non-medical emergencies.

Findings included:

- Staff H, interviewed on 4/28/10 at 10:30am and 12:05pm, acknowledged the CAH failed to conduct or participate in at least two non-medical emergency drills within the last year for emergencies which are consistent with the location of the CAH. Staff H acknowledged the risk for tornadoes and other adverse situations in the area of the CAH.

Further interview with staff H, at that time, confirmed knowledge of the state-wide tornado drill conducted in March 2010. Staff H stated the CAH chose to select another time to conduct a tornado drill at their convenience. Staff H stated the drill had not yet been conducted and no drill is scheduled. The CAH failed to provide education and document staff preparedness in non-medical emergencies which may occur in the area where the CAH is located.

- Staff H, interviewed on 4/28/10 at 10:30am and 12:05pm, acknowledged the CAH failed to develop and implement emergency preparedness plans to ensure patient safety during an emergency. Staff H, on 4/29/10 at 12:05pm confirmed several different emergencies that may occur in the area related to the proximity of a highway, grain elevator, etc. Staff H, confirmed the CAH failed to develop and implement a comprehensive plan to ensure the safety and well being for patients during a local emergency.

- Staff H, on 4/28/10 at 12:05pm, confirmed no staff education had been conducted for the handling of non-medical emergencies.

Based on observation, document review and interview the governing body of the Critical Access Hospital (CAH) failed to maintain accountability for the maintenance and housekeeping procedures, failed to assure only pharmacists labeled and dispensed medications, to develop an active surveillance program, to designate an outpatient services coordinator, to develop and maintain a current list of services provided by agreement or arrangement, to develop an individualized plan of care and failed to develop and implement the required guidelines to direct their swing bed program.

Findings included:

- The CAH failed to assure all equipment is maintained for safe operating conditions, to assure the premises are clean and orderly, to develop and implement a plan for emergency fuel for the diesel powered generator and emergency water supply and to assure the safety of patients in non-medical emergencies as evidenced at CFR.623.

- The CAH failed to assure only pharmacists labeled and dispensed medications for outpatient and emergency room patients, to develop an active surveillance program to prevent and detect infections, educate staff and investigate infections, to designate a coordinator of outpatient services, to develop and maintain a current list of services provided by agreement or arrangement and to develop and individualized plan of care and as evidenced at CFR 485.635.

- The CAH failed to provide the swing bed patients with a complete copy of their patient rights, to develop a process to assure the swing bed patients had appropriate and complete transfer, and discharge rights, to report and investigate potential patient abuse, to establish an on-going activity program directed by a qualified staff member, to assure all swing bed patients had a comprehensive nursing assessment and to assure all swing bed patients had a comprehensive plan of care to meet their needs as evidenced at CFR 485.645

Based on observation document review and interview the Critical Access Hospital (CAH) failed to assure only pharmacists labeled and dispensed medications, failed to develop an active surveillance program to prevent and detect infections, educate staff and investigate infections, failed to designate a coordinator for outpatient services, failed to develop and maintain a current list of services provided by agreement or arrangement, failed to develop an individualized plan of care for 17 (#'s 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, 33, 34, 35, 36 and 37) of 20 inpatient records reviewed.

Findings included:

- The CAH failed to assure only pharmacists labeled and dispensed medications for outpatient and emergency room patients as evidenced at C-276, CFR 485.635(a)(3)(iv).

- The CAH failed to develop an active surveillance program to prevent and detect infections, educate staff and investigate infections as evidenced at C-278, CFR 485.635(a)(3)(vii).

- The CAH failed to designate a coordinator of outpatient services as evidenced at C-281, CFR 485.635(b)(1).

- The CAH failed to develop and maintain a current list of services provided by agreement or arrangement as evidenced at C-291, CFR 485.635(c)(3).

- The CAH failed to develop an individualized plan of care for 17 (#'s 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, 33, 34, 35, 36 and 37) of 20 inpatient active and closed records reviewed as evidenced at C-298, CFR 485.635(d)(4).

Based on observation, document review and staff interview the Critical Access Hospital (CAH) failed to assure only the pharmacist labeled and dispensed an interim supply of prepackaged medications for outpatient and emergency room patients to take home until their prescription can be filled.

Findings included:

- Review of the Kansas Pharmacy Law section at 68-7-11 for Medical Care facility pharmacy directs the pharmacist-in-charge shall be responsible for developing programs and supervising all personnel in the distribution and control of drugs and all pharmaceutical services at the medical care facility. The pharmacist -in-charge will develop policies and procedures governing the storage, control, and distribution of drugs.

The Pharmacy Law states, "The registered professional nurse shall not transfer a drug form one container to another for future use, but may transfer a single dose from a stock container for immediate administration to the ultimate user."

- Review of the pharmacy contract dated 5/20/98 revealed the consultant pharmacist shall be responsible for developing and monitoring an acceptable medication distribution system for the CAH.

- Observation of a drawer in the pharmacy revealed blank pill bottle labels. Interview with administrative staff A on 4/28/10 at 9:00am explained the nursing staff used the blank labels for medication they put in the pill bottles for outpatient and emergency room patients. Staff A stated the nurses locate the medication in the pharmacy and complete the label with patient's name, name of the medication, directions to take the medications, the number of pills dispensed and a designated pharmacy number. The nurse then provided the medications to the patients to use at home.

Review of the hospital's policy for procurement of drugs for outpatients policy #NS-21-1 lacked evidence of any direction for the nurses to not dispense stock medications to the outpatients.


Interview with pharmacy staff X on 4/28/10 at 9:15am revealed they were unaware of the nurse's dispensing practices. Staff X reported they pre-fill small plastic bags with medications and place a label with the required information on it that the nurse completes with the patient's and physician's name on it, after the physician writes the order. The nurse administers the pre-filled package to the outpatient and/or emergency room patient.

Interview with pharmacy staff Y on 4/29/10 at 10:00am stated they viewed the nursing practice as medication dispensing and reported they were unaware of this practice in the CAH. Staff Y acknowledged they are not involved with policy and procedure development.

The Critical Assess Hospital (CAH) reported an average daily census of eight patients. Based on observation, document review and interview, the CAH failed to develop an active surveillance program that included measures to prevent and detect infections, educate CAH staff and investigate infections.

Findings included:

- The CAH provided a list of key personal at surveyor request. The document listed staff E as the infection control officer. Staff E, interviewed on 4/28/10 at 11:00am, denied they are the infection control officer. Staff E stated they collect data, but do not perform critical analysis of the information collected. Staff E then stated Administrative Staff A is the infection control officer. Interview with staff A on 4/29/10 at 10:55am confirmed staff E is the designated infection control officer. Staff A further acknowledged there is no additional information regarding the CAH's infection control program. Staff E, on 4/29/10 at 11:55am, confirmed the CAH failed to perform active surveillance for the prevention and detection of infections, failed to prevent infections and failed to investigate infections.

- Review of the CAH's plan for "Surveillance for Hospital Acquired Infections" revealed the CAH's plan is to "monitor for and detect the cause and effect of nosocomial infections and implicate actions that would decrease the rates of the Hospital Acquired Infections". The plan directs staff to monitor intravenous catheter sites, Foley (urinary) catheters, laboratory reports, antibiotic therapy and elevated patient temperatures. The plan failed to identify methods to prevent infections. Interview with staff E on 4/29/10 at 11:55am confirms the CAH failed to create a plan to prevent infections.

The plan directs the infection control to periodically screen to assure a "safe and clean environment" and must inform the Director of Nursing and the laboratory staff with the findings of the observations. Staff E on 4/29/10 at 11:55am confirmed the lack of periodic screening of the CAH.

- Review of the Infection Control data sheet, created for each patient, revealed data collected for type of infection, signs and symptoms- including "soft tissue, diarrhea, respiratory, urinary or other symptoms including chills, jaundice, swelling, uterine tenderness, cervicle (sic) discharge or eye discharge". Other special information to be collected included elevated temperature and laboratory results, if the patient had a urinary catheter and if the patient receive antibiotics. The CAH failed to assess for infection preventative measures, prevention of spread of infections and patient history of infections.

- Review of the CAH policy titled "Laundry Procedures" directs staff to sort the soiled linens. Observation on 4/27/10 at 10:00am of the laundry area revealed piles of sorted soiled laundry on the table. The items are sorted and stored on a table including pads which may be soiled with urine, feces or other bodily fluids, bedspread, personal clothing, bedding, and towels and washcloths. An open, red biohazard bag is also on the table. Staff I, at that time, confirmed the presence of the biohazardous items next to the laundry that requires regular handling. The items on the table also touch the walls. Staff F, interview on 4/27/10 at 9:30am revealed the lack of knowledge to disinfect the surfaces in contact with contaminated items.

- Observation of the laundry area on 4/27/10 at 9:30am revealed a flush-rim sink. Staff F, interviewed at that time, revealed cloth items with soiling are pre-rinsed and soaked. Review of laundry policies revealed the lack of a policy addressing the pre-rinsing and soaking of cloth items.

- Staff G provided patient care on 4/28/10 at 9:45am. Staff G entered the patient room and applied gloves without hand hygiene. Staff G provided the care, removed the gloves, exited the patient's room and entered the soiled utility room to place soiled linens in the uncovered hamper. Staff G then went to the nurses' station and drank from a cup. Staff G, interviewed at that time, confirmed the lack of hand hygiene before applying gloves, when gloves were removed and after soiled linens were placed in the non-covered hamper.

Review of the CAH's policy titled "Handwashing Summary" IC-6 directs staff to perform hand hygiene before going off duty, but failed to identify when hand hygiene is to be performed during patient care and when at work. CAH policy titled "Hand Washing Practices for the Prevention of Infections" IC-7 identified the need to perform hand hygiene between direct patient care, but failed to direct hospital staff when and how to perform hand hygiene.

- Staff G, observed on 4/27/10 at 2:15pm revealed the staff member dragging a plastic bag containing linens on the floor from the patient care area to the laundry room. Additional observation on 4/29/10 at 2:15pm, revealed staff G carrying a bag of soiled linens over the shoulder, against their back and uniform.

Review of CAH policy titled "Nursing Service and Hospital Employees" IC-1 directs staff to "never touch the floor" with the plastic bag and "with minimal contact with the uniform".

- Interview with staff H on 4/27/10 at 10:30am revealed the lack of knowledge of the contact time for the hospital's chemical to provide disinfection. Interview with administrative staff A on 4/28/10 at 5:30pm confirmed the infection control committee and infection control officer lacked input into the disinfectant the hospital uses and confirmed the lack of knowledge of the required contact time for the chemical to disinfect. Staff A acknowledged the lack of knowledge of the manufacturer's contact time for the spray disinfectant used in some hospital departments including radiology. Staff A confirmed the lack of knowledge of the items stored on the floor, the chipped wooden doors, the bugs in the light covers, the handling of linens when collected from the patient care areas and in the laundry processing area.

- On 4/28/10 review of information provided by the CAH on the Buckeye brand "Terminator" one-step disinfectant and Mint Quat, revealed the chemical disinfectant must remain wet on surfaces for 10 minutes.

Observation on 4/28/10 at 8:55am revealed staff F cleaning room 106. Staff F wearing gloves, wiped the sink, bedside stand and overbed table using the "Terminator" one-step disinfectant solution. The sink remained wet for a contact time of two minutes. The bedside stand and overbed table remained wet for a contact time of two minutes and 10 seconds. Staff F sprayed the toilet seat with the Terminator one-step disinfectant. The surfaces remained wet for a contact time of six minutes. Staff F wet mopped the floor using Mint Quat cleaning solution which dried in five to eight minutes, not the required 10 minutes for disinfection. The CAH failed to assure proper use of the chemicals for surface disinfection.

On 4/28/10 at 9:20am, staff F lacked acknowledged of the contact time for disinfection and verified the floor remains wet "about five minutes".

On 4/28/10 at 9:30am, staff I acknowledged they were unaware the surfaces must remain wet with the cleaning solution for 10 minutes in order to achieve disinfection of the surfaces.


- Staff E, interviewed on 4/28/10 at 11:00am, revealed the CAH failed to collect information regarding employee illness for more than one year. Staff E, at that time, presented the "call in" log, but stated not all employee illnesses are logged and reported to infection control. Staff E further confirmed staff illnesses are not included in infection control information and practices.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to designate an outpatient coordinator to be responsible for all out-patient services provided by the CAH.

Findings included:

- On 4/26/10 the "Hospital Information Sheet" (a staff roster requested by the surveyor) completed by the CAH lacked the name of a staff member in charge of the outpatient services.

Staff C on 4/26/10 at 2:45pm acknowledged the CAH failed to appoint an out-patient coordinator to be responsible for all outpatient services.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to develop and maintain a current list of services provided by agreement or arrangement and the nature and scope of the services provided.

Findings included:

- On 4/26/10 at 11:40am during entrance, the surveyor requested a list of services the facility provides directly and a list of services provided through arrangement or agreement. The CAH failed to provide documentation for description of services provided by the CAH directly and by agreement or arrangement. Additional requests for documentation of services provided by the CAH were made 4/26/10 and 4/28/10. The CAH could not provide a complete list of services provided by agreement or arrangement to the surveyor.

Staff B on 4/27/10 at 3:00pm acknowledged the CAH lacked a complete list of services provided by agreement or arrangement.

Based on observation, document review and staff interview the Critical Access Hospital (CAH) failed to assure the nursing staff developed individualized plans of care for 17 of the 20 inpatient active and closed records reviewed (patient #s 12, 14, 15, 16, 17, 18, 19. 20, 21, 22, 23, 25, 33, 34, 35, 36 and 37).

Findings included:

- Review of patient # 19's medical record revealed an admission date of 4/25/10 after they fell at home and had complaints of pain. Review of the medical record lacked evidence of a plan of care for this patient.

- Review of patient #20's medical record revealed an admission date of 4/24/10 after a fall at home. Observation of the patient on 4/26/10 at 1:00pm revealed the patient in bed with a personal alarm attached to them, a gauze bandage on their right hand and a urinary catheter in place. Interview with nursing staff N on 4/26/10 at 1:10pm revealed the patient had a skin graft and orders not to change the dressing until after their next physician appointment. Review of the medical record lacked evidence of an individualized plan of care for this patient.

- Review of patient #21's medical record revealed an admission date of 4/16/10 after a fall at home. Review of the physician progress notes dated 4/16/10 revealed the patient was also a hospice patient. Review of the medical record lacked evidence of an individualized plan of care and a hospice plan of care for this patient.

- Non-compliance with individualized plan of care also affected patient #s 12, 14, 15, 16, 17, 18, 22, 23, 25, 33, 34, 35, 36 and 37.

Staff C on 4/27/10 at 7:30am acknowledged the failed to complete a plan of care to identify the patient's nursing and care needs.

The Critical Access Hospital (CAH) reported an average daily census of eight patients. Based on interview and document review, the CAH failed to evaluate hospital-acquired infections and medication therapy.

Findings included:

- Review of the Quality Assurance (QA) Plan of the CAH revealed the plan lacked evidence of the specific data to be collected for QA assessment of the infection control program.

- Staff E, identified by the CAH as the infection control officer, interviewed on 4/29/10 at 11:00am confirmed the CAH collected data regarding the hospital-acquired infections and the use of antibiotics, but failed to perform critical review of the data. Staff E further confirmed the CAH failed to review the active surveillance of infections, measures to prevent and detect infection and education of staff.

The hospital reported a census of six swing bed patients with five medical records reviewed. Based on observation, document review and staff interview the hospital failed to develop and implement the required guidelines to direct their swing bed program assuring the needs of all swing bed patients are met.

Findings included:

- The hospital failed to provide the swing bed patients with a complete copy of their rights as evidenced at C-360, CFR 485.645 (d).

- The hospital failed to develop a process to assure the swing bed patient had appropriate and complete transfer, and discharge rights as evidenced at C-373, CFR 483.12 (a).

- The hospital failed to report and investigate potential patient abuse as evidenced at C-382, CFR 483.13 (b).

- The hospital failed to establish an on-going activity program directed by a qualified staff member as evidenced at C-385, CFR 483.15 (f).

- The hospital failed to establish an on-going social services program directed by a qualified staff member as evidenced at C-386, CFR 483.15 (g).

- The hospital failed to assure all swing bed patients had a comprehensive nursing assessments as evidenced at C-388, CFR 483.20.

- The hospital failed to assure all swing bed patients had a comprehensive plan of care to meet their needs as evidenced at C-395, CFR 483.20 (b) (2).

The hospital reported a census of six swing bed patients with five medical records reviewed. Based on document review and staff interview the hospital failed to provide a complete copy of their swing bed rights for 5 of 5 patients reviewed (patient #'s 26, 27, 28, 29 and 30).

Findings included:

- Review of the Hospital's Swing Bed Patient Rights, dated 11/09 lacked evidence of a complete notice of the following patient rights:

1. "The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition;"

2. "(?483.10(b) (5) The facility must-

(i) Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of-

(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;

(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and

(ii) Inform each resident when changes are made to the items and services specified in paragraphs (5)(i) (A) and (B) of this section."

"(?483.10(b )(6) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate."

3. "[The resident has the right to-]

Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being; and"

4. "The resident has the right to-

(1) Refuse to perform services for the facility;

(2) Perform services for the facility, if he or she chooses, when-

(i) The facility has documented the need or desire for work in the plan of care;

(ii) The plan specifies the nature of the services performed and whether the services are voluntary or paid;

(iii) Compensation for paid services is at or above prevailing rates; and

(iv) The resident agrees to the work arrangement described in the plan of care."

Interview with administrative staff A on 4/27/10 at 8:50am reported the hospital's "Mock Survey identified the swing bed rights were incomplete, but we did not know that we needed to correct them and failed to assure the patients received a complete copy of their rights. "

The hospital reported a census of six swing bed patients with five medical records reviewed. Based on document review and staff interview the hospital failed to develop a swing bed transfer process and policy required by this regulation.

Findings included:

- Review of the swing bed transfer form and policy on 4/27/10 provided by administrative staff A revealed they provided the hospital's EMTALA transfer documentation.

Interview with administrative staff A on 4/27/10 at 8:50am, reported they provided the only transfer documentation that the hospital had and lacked a specific policy and process for swing bed patients.

The hospital reported a census of six swing bed patients with five medical records reviewed. Based on observation, document review and staff interview the hospital failed to report and investigate potential patient abuse for patient #29 and failed to develop a policy to report and investigate abuse allegations.

Findings included:

- Observation of patient #29 with licensed staff K on 4/28/10 at 3:00pm revealed the patient had four bruises ranging from 1 cm (centimeter) to 1.5 cm on their inner left and right thigh and three older yellowing bruises on the front of their left calf. During the observation staff K changed the patient's gown and revealed the patient's left shoulder. Their shoulder appeared swollen and had a 17cm by 7cm dark red to green bruise. The patient could not recall how the injury occurred.

Interview on 4/28/10 at 4:30pm, the patient reported they thought the injury occurred when the staff repositioned them in the bed and reported staff use the turn pad for repositioning now.

Review of the hospital's lifting and moving patient's policy #NS22-35 revised on 8/17/98 directed the staff to "slide their hands palms up under the patient's shoulders and hips to support the patient's weight and move the patient up in the bed.

On 4/28/10 at 5:00pm review of patient #29's medical record and computerized nursing notes lacked evidence of any notations of the injury or the presence of the current bruising. Review of the physician orders revealed an order dated 4/24/10 for a shoulder x-ray due to the complaint of pain. Review of the report revealed the x-ray lacked evidence of a fracture.

Interview with non-licensed staff G on 4/28/10 reported they gave the patient a whirlpool bath on 4/23/10 and the patient lacked evidence of any injuries at that time.

Interview with non-licensed staff W on 4/28/10 stated they cared for the patient over the weekend and reported the patient did not have any injuries.

Review of the hospital's charge nurse policy revised on 3/20/00 revealed the charge nurse will report all unusual occurrences to the Director of Nursing.

Interview with administrative staff members A and B on 4/28/10 at 5:10pm reported they lacked an incident report for patient #29's injury.

Interview on 4/29/10 at 8:00am with administrative staff A stated they lacked documentation of the injury but located a pain notation that stated the patient's shoulder appeared swollen on 4/24/10.

Review of the abuse policy, 1/1/10, listed descriptions of the types of abuse for staff to report but lacked direction of what to do if they suspect abuse.

Interview with administrative staff A on 4/29/10 at 8:30am reported the hospital lacked a policy to direct the staff to report and investigate suspected abuse.

Based on document review and staff interview the hospital failed to follow their established policy for criminal background checks for one employee (staff L) who was responsible for swing bed patients.

Findings included:

- Review of staff L's employment record with a hire date of 4/15/09, lacked evidence of a criminal back ground check upon their employment.

Review of the hospital's policy for Background checks revised on 3/4/10 revealed the hospital will complete criminal background checks for certain employees and maintain the results in the employment records.

Interview with Administrative staff A on 4/29/10 at 10:00am reported the hospital failed to complete the background checks for non-licensed staff L.

The hospital reported a census of six swing bed patients with five medical records reviewed. Based on observation, document review and staff interview the hospital failed to establish an activity program and failed to employ activity staff to meet the needs of the swing bed patients.

Findings included:

- Review of the hospital's activities and recreational policy #NUS-SB 35 dated 1/1/10 directed the staff to complete a comprehensive assessment of the patient and periodic reassessments to select activities for the patients. The policy suggested potential activities for all levels of functioning patients such as: reading articles to patients, using different textures to stimulate patients, offering crafts, games and expanding the program of include gardening for the higher functioning patients. The policy stated the activity program will be under the direction of a qualified staff member.

- Observations on 4/26/10 at 11:00am of the swing bed patient rooms, hall and nurses station lacked evidence of an activity calendar. Observations of the unit between 11:00am and 5:00pm lacked evidence of any activities provided to the patients.

Interview with administrative staff C on 4/27/10 at 4:00pm reported the hospital lacked an activity director and reported the swing bed patients "can go to the nursing home next door for activities for a fee." Staff C reported on 4/27/10 at 8:40am the hospital lacked a contract for patients to attend activities at the nursing home and the specified fee to attend.

Review of the hospital's patient activity policy #SB-11 dated 11/7/96 revealed the hospital will have an activity trained aide to coordinate activities, provide activities of interest and document their activity program on the patient's plan of care.

Review of the computerized and written medical records for all five swing bed patients lacked evidence of any plan of care, current activity assessments or documented activities since December 2009.

Interview with administrative staff A on 4/27/10 at 9:45am, reported the hospital lacked an on-going activity program for the swing bed patients, lacked a staff member to provide activities and stated since they converted to the computerized system they lacked documentation of any activities provided to the patients and activity assessments.

The hospital reported a census of six swing bed patients with five medical records reviewed. Based on document review and staff interview the hospital failed to establish a social services program and hire a qualified Social Services Designee to meet the needs of the swing bed patients.

Findings included:

- Interview with administrative staff A on 4/26/10 at 11:00am identified staff O as the Social Services Designee and Swing Bed Coordinator.

Review of the hospital's Social Services Designee Job Description revised on 11/25/96 revealed the staff member will have a certification for a Social Services Designee.

Review of staff O's employment record with a hire date of 11/24/97 revealed a note dated 1/29/09 that indicated the employee acknowledge their responsibility for social services for the swing bed patients.

Review of the hospital's new employee Check List, not dated, revealed the employee will sign this form to demonstrate they received a copy of their job description.

Staff O's record lacked evidence of a job description or job tasks related to this position and lacked a performance evaluation, competency and a certification for this position.

Interview with staff O on 4/29/10 at 11:00am reported they lacked knowledge of being the designated Swing bed coordinator and social services designee. Staff O stated they do not have any specific swing bed responsibilities and reported they have assisted in updating the swing bed policies.

Interview with administrative staff A on 4/29/10 at 1:00pm revealed staff O lacked certification or training for the swing bed coordinator and social services designee.

The hospital reported a census of six swing bed patients with five medical records reviewed. Based on observation, document review and staff interview the hospital failed to assure the staff completed comprehensive assessments of the patients total health status, activity interests and functional abilities to meet the needs of the swing bed patients. Failure to properly assess the patients has the potential to affect all swing bed patients at the hospital.

Findings included:

- Review of patient # 29's medical record revealed an admission date of 8/29/09 after a fall at home. Review of the initial nursing assessment lacked evidenced of the following: customary routine, cognitive patterns, ability to communication, vision, mood and behavior patterns, activity pursuit, medications, special treatments and procedures, discharge potential and documentation of participation in assessment.

Observation of patient #29 with licensed staff K on 4/28/10 at 3:00pm revealed the patient had four bruises ranging from 1 cm (centimeter) to 1.5 cm on their inner left and right thigh and three older yellowing bruises on the front of their left calf. During the observation staff K changed the patient's gown and revealed the patient's left shoulder. Their shoulder appeared swollen and had a 17cm by 7cm dark red to green bruise. At that time the patient could not recall how the injury occurred.

Interview on 4/28/10 at 4:30pm with patient #29 revealed they thought the injury occurred when staff repositioned them in the bed. "Staff used the turn pad for repositioning now. "

Review of the hospital's lifting and moving patients policy #NS22-35 revised on 8/17/98 directed the staff to "slide their hands palms up under the patient's shoulders and hips to support the patient's weight and move the patient up in the bed.

On 4/28/10 at 5:00pm review of patient #29's medical record and computerized nursing notes lacked evidence of any notations of the injury, the presence of the current bruising and lacked an assessment to determine the extent of the patient's injury.

Interview with administrative staff members A and B on 4/28/10 at 5:10pm reported the medical record lacked a nursing assessment to determine the extent of patient #29's injury.

- Observation of patient #26 on 4/26/10 at 2:00pm revealed them sitting in a chair with a cast on their right arm which was propped on a pillow and in a sling.

Review of patient #26's medical record revealed an admission dated of 4/20/10 with a diagnosis of a fractured humorous. Review of the record lacked evidence of a comprehensive admission assessment that included the following: customary routine, cognitive patterns, ability to communication, vision, mood and behavior patterns, activity pursuit, medications, special treatments and procedures, discharge potential and documentation of participation in assessment.

- Non-compliance with completion of comprehensive nursing assessment also affects patient #'s 27, 28 and 30.

- Interview with administrative staff C on 4/27/10 at 1:00pm reported the hospital implemented a new computer program in January 2010. Staff C stated the vender has installed the software program in different phases and stated the staff has not began the plan of care phase at this time. Staff C reported the staff failed to complete a paper plan of care to identify the patient's nursing and care needs, after they reviewed patient #26's medical record.

- Review of the hospital's activities and recreational policy #NUS-SB 35 dated 1/1/10 directed the staff to complete a comprehensive assessment of the patient and periodic reassessments to select activities for the patients. The policy suggested potential activities for all levels of functioning patients such as: reading articles to patients, using different textures to stimulate patients, offering crafts, games and expanding the program of include gardening for the higher functioning patients. The policy stated the activity program will be under the direction of a qualified staff member.

Review of the computerized and written medical records for all five swing bed patients lacked evidence of any current activity assessments to determine the patients' activity interests.

Interview with administrative staff A on 4/27/10 at 9:45am, reported the records lacked evidence of an activity assessment to meet the needs and interests of the patients.

The hospital reported a census of six swing bed census with five records reviewed. The hospital failed to assure the staff completed a compressive plan of care for 5 of 5 swing bed patients (# 26, 27, 28, 29 and 30).

Findings included:

- Review of the hospital's policy for skilled and swing bed patients, not dated, directed the staff to assure the patients participated in weekly care plan meetings and document progress regarding discharge and psycho-social needs. The policy stated all care plans will be reviewed every 90 days, or with significant changes, and adjusted according to progress.

- Observation of patient #26 on 4/26/10 at 2:00pm revealed them sitting in a chair with their arm in a cast and propped on a pillow with a sling.

Review of patient #26's medical record revealed an admission dated of 4/20/10 with a diagnosis of a fractured humorous. Review of the record lacked evidence of a Plan of Care and the patient's participation of assisting with their plan of care.

- Review of patient #27's medical record revealed an admission dated of 4/19/10 with a diagnosis of a brain infarct (stroke) and required physical therapy services. Review of the patient's history and physical revealed they had a pressure sore at admission with directions to leave the pressure sore open to air.

Interview with licensed staff N on 4/27/10 at 2:50pm reported the patient had an abrasion/scrape from a recent fall at home, not a pressure sore.

Observation of patient #27 with staff N on 4/27/10 at 2:55pm revealed a palm size superficial abrasion and a bruise, on the patient's left hip. Observation revealed the patient was dependent on staff for all personal care and had a urinary catheter.

Interview with patient #27 on 4/27/10 at 3:00pm revealed the patient had moderate confusion.

Review of the medical record lacked evidence of a Plan of Care to direct the staff on the patient's nursing and care needs and their involvement or a representative ' s involvement in the development of a care plan.

- Review of patient #28's medical record revealed an admission dated of 1/1/10 with a diagnosis of a cerebral vascular accident (stroke) and dementia.

Interview with licensed staff N on 4/27/10 at 2:50pm reported this patient was an intermediate swing bed patient.

Observation and interview with patient #28 on 4/27/10 at 1:30pm revealed the patient sitting up in their chair watching television. Interview with this patient revealed they were pleasantly confused.

Review of the medical record lacked evidence of a Plan of Care to direct the staff on the patient's nursing and care needs and their involvement or a representative's involvement in the development of a care plan.

- Non-compliance with care plans also affected patient #s' 29 and 30.

- Interview with administrative staff C on 4/27/10 at 1:00pm reported the hospital implemented a new computer program in January 2010. Staff C stated the vender has installed the software program in different phases and stated the staff has not began the plan of care phase at this time. Staff C reported the staff failed to complete a paper plan of care to identify the patient's nursing and care needs, after they reviewed patient #26's medical record.