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I. Based on observation, policy/ procedure review and staff interview, the Nursing Staff failed to ensure patient care supplies, located in Hope Harbor unit, Physical Therapy and Occupational Therapy units were not expired. The CAH had a census of 14 current patients. The Director of Occupation therapy reported approximately 15 outpatients daily and approximately 3 inpatients daily.

Failure to retain current medical supplies for patient care could potentially harm patients by using supplies that the manufacturer determined might be ineffective due to being outdated and expose patients to supplies that may no longer be sterile and/or potentially less effective.

Findings include:

1. Observation during the environmental tour of Hope Harbor unit on 3/29/11 at 10:00 AM, with Staff H, Director of Hope Harbor, revealed a storage room with the following expired supplies available for patient use:

a. 1- nasal pharyngeal airway expired 4/10.
b. 1- 18 gauge intravenous (IV) catheter expired 1/10.
c. 1- pedicap carbon dioxide detector expired 3/06.
d. 1- easy cap II carbon dioxide detector expired 6/07.
e. 4- 18 gauge needles, 3 expired 8/06 and 1 expired 7/06.
f. 3- 20 gauge needles expired 8/06.
g. 2- 20 gauge insyte autogard needles, 1 expired 1/05 and 1 expired 7/05.
h. 2- 18 gauge insyte autogard needles, 1 expired 1/10 and 1 expired 8/04.
j. 3- 22 gauge insyte autogard needles expired 1/05.

2. During an interview on 3/29/11 at 10:00 AM, Staff H said pharmacy staff was responsible for checking and removing outdated supplies in the storage room. Staff H acknowledged the identified supplies were all expired and should not be available for patient care.

3. Review of the CAH policy titled Purchasing Department Infection Control Policies, dated 12/01 revealed in part ... "C. Stock is rotated so that oldest items are placed in front each time a new shipment is stored. Any items, which are obsolete, as indicated by expiration date or other sign of obsolescence, or show signs of deterioration or damage shall be removed from storage and properly disposed of."

4. . Observations, during a tour of the Occupational Therapy (OT) unit, on 3/25/11 at 3:30 PM, revealed the following expired supplies in a supply cupboard located in the OT patient care area available for patient use:
a. 6 of 6 Xeroform dressings expired 5/2006
b. 26 of 26 Tegaderm 6x7 centimeter (cm) bandages expired 5/2007
c. 16 of 16 Tegaderm 10x12 cm bandages expired 10/2009
d. 1 of 1 Tegaderm 10x12 cm bandage expired 5/2007
5. During an interview, at the time of the observation, the Director of Occupational therapy acknowledged the expired supplies in the supply cupboard. The Director stated the occupational therapy staff monitor for expired supplies daily and document this on the "Rehab Maintenance schedule."

6. Review of flowsheet titled " Rehab Maintenance Schedule, March 2011" showed
occupational therapy staff documented no expired supplies in the Occupational therapy Unit from 3/1/11 to 3/25/11.



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II. Based on observation, review of policies and procedures, and staff interviews, the Critical Access Hospital (CAH) staff failed to secure 8 of 28 empty oxygen cylinders found on the loading dock. The CAH administrative staff reported a census of 14 patients at the time of the observation.

Failure to secure empty oxygen cylinders could potentially result in the cylinders falling breaking the top. Any pressurized oxygen remaining in the cylinder could cause the top to blow off potentially with enough pressure to go through a wall. Additionally, unsecured cylinders could add fuel to a fire if knocked over breaking the top.

Findings include:

1. Observation on 3/29/11 at 8:43 AM, with Staff A, Director of Maintenance and Staff C, Director of Quality; revealed 8 small unsecured oxygen cylinders on the loading dock, the loading dock contained 20 secured oxygen cylinders of various sizes.

2. Review of CAH policy titled "Oxygen/Compressed Gas Safety" revised 1/08, on 3/29/11 revealed, in part ..."Purpose - Assure an adequate supply of oxygen is available for use in the hospital. To store and use compressed gases in the safest possible manner...Compressed Gas Use Procedures - Chains, special boxes, or other methods of securing the cylinders in a positive manner shall be used at all times..."

3. During an interview on 3/29/11 at 8:43 AM, Staff A reported that housekeeping staff transport the empty cylinders to the loading dock and do not always secure them.

Based on review of medication error reports, policy review, and staff interview, the nursing staff failed to notify the physician when medication errors occurred for 11 of 20 Patients, (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11). The CAH had a current census of 14 patients.

Failure to report medication errors to the physician could potentially cause harm to patients if they received the wrong medication, medication at the wrong time or by the wrong route.

Findings include:

1. Review of the CAH policy titled Incidence/ Occurrence Reporting revised 9/10, revealed in part... "3. If indicated, based on the nature of the incident, report the incident to the patient's attending physician or on-call physician. A. 1. Error: An unintended act, either of omission or commission, or an act that does not achieve its intended outcome."

2. Review of patient medication event reports revealed:

a. The Medication Occurrence report for Patient #1 dated 3/2/10 at 4:00 AM revealed Patient #1 received Tylenol 650 mg (milligrams) by mouth without a physician order. Nursing staff failed to notify the physician an error occurred.

b. The Medication Occurrence report dated 3/4/10 at 10:00 PM revealed Patient #2 received Coumadin (blood thinner) without a physician order. Nursing staff failed to notify the physician an error occurred.

c. The Medication Occurrence report dated 3/14/10 at 8:00 PM revealed Patient #3 received Amicar (prevents bleeding) intravenous at 10 ml (milliliters) an hour instead of 20 ml an hour. The physician ordered the medication for 20 ml an hour. Nursing staff failed to notify the physician an error occurred.

d. The Medication Occurrence report dated 1/22/11 at 9:30 PM revealed Patient #4 did not receive Prevacid (heartburn medication) as ordered by the physician. Nursing staff failed to notify the physician an error occurred.

e. The Medication Occurrence report dated 1/24/11 at 4:00 PM revealed Patient #5 did not receive Ferrous Sulfate (iron supplement) three times a day and dulcolax suppository (For constipation) for 1 day as ordered by the physician. Nursing staff failed to notify the physician an error occurred.

f. The Medication Occurrence report dated 1/31/11 at 2:00 AM revealed Patient #6 received a medication infusion (no medication identified) earlier than ordered by the physician. Nursing staff failed to notify the physician an error occurred.

g. The Medication Occurrence report dated 1/9/11 at 9:00 AM revealed Patient #7 did not receive Rocephin 2 grams (antibiotic) intravenous (IV) as ordered by the physician. Nursing staff did not puncture the antibiotic vial correctly resulting in the medication not mixing with the diluent. Nursing staff failed to notify the physician an error occurred.

h. The Medication Occurrence report dated 1/5/11 at 12:00 PM revealed Patient #8 received the wrong IV medication D 5 LR (IV fluid with dextrose) instead of LR (IV fluid without dextrose) as ordered by the physician. Nursing staff failed to notify the physician an error occurred.

i. The Medication Occurrence report dated 2/18/11 at 7:00 AM revealed Patient #9 did not receive 2 doses of medication, Prevacid and Nortriptyline (antidepressant) as ordered by the physician. Nursing staff failed to notify the physician an error occurred.

j. The Medication Occurrence report dated 2/14/11 at 10:45 PM revealed Patient #10 did not receive Pulmicort nebulizer (breathing treatments) as ordered by the physician. Nursing staff failed to notify the physician an error occurred.

k. The Medication Occurrence report dated 2/23/11 at 10:15 AM revealed Patient #11 had an IV fluid bag hanging and infusing for 48 hours. The nursing staff were to change the IV bag every 24 hours. Nursing staff failed to notify the physician an error occurred.

3. During an interview on 3/31/11 at 7:30 AM, Staff C Executive Director of Quality, reported that nursing staff were not notifying the physicians when medication errors occurred. Documentation on the Medication Occurrence forms lacked evidence that nursing staff had notified the physicians of the medication errors. Nursing staff should notify the physicians when medication errors occur.

I. Based on document review, observation, and staff interview, the dietary staff failed to maintain sanitary conditions evidenced by the carbon build up on the stove, the shelf above the stove and 4 fry pans.

The Critical Access Hospital (CAH) administration reported a census of 14 patients. The Dietitian reported the dietary staff provided approximately 276 meals per day.

Failure to maintain a clean and sanitary kitchen environment could potentially result in contamination of the patient's food.

Findings include:

1. Observation, during initial tour, on 3/29/11 at 8:50 AM, revealed carbon buildup on the back splash of the stove, under and around the edges of the shelf above the stove. Observation, also noted, a white residue that surrounded the 6 burners on the stove.

Observation in the dishwasher area revealed a rack suspended from the ceiling with 8 frying pans. Examination of the frying pans revealed 4 of the frying pans contained carbon build up on the cooking surface of the pans.

The Dietary Manager used an ink pen to scratch off part of the carbon buildup and white residue on the stove, burners and frying pans.

2. Review of the CAH policy, "Food Service Safety-Nutrition services" revised 8/04 revealed in part, "...specific safety precautions must be taken...keep...ovens free from film of grease to prevent fires..."

Review of the CAH policy, "Nutrition Services/Infection Control", revised date 12/09 revealed in part, "...equipment shall be kept clean...and shall be free from corrosion..."

3. Review of the Cleaning Schedule dated January 2011 revealed in part, "...stove and top/burners...cleaned weekly...." The cleaning schedule provided a space for staff to sign and date when they completed the task. Review of the January 2011 cleaning schedule revealed no signature or date that documented when staff cleaned the stove and top/burners.

4. During an interview on 3/30/11 at 2:20 PM, the Dietary Manager stated, the staff are to clean the stove weekly and sign the task off on the schedule. The Dietary Manager confirmed the January 2011 cleaning schedule lacked signatures and dates that showed when the staff last cleaned the stove and burners. The Dietary Manager stated, "I don't have any schedule for February and March of 2011. I do not have anything to show when the last time staff cleaned the stove and burners."

The Dietary Manager stated staff should have thoroughly cleaned the frying pans after each use.

II. Based on document review, observation and staff interview, the dietary staff failed to maintain sanitary practices during observed meal preparation.

The CAH administration reported a census of 14 patients. The Dietitian reported the dietary staff provided approximately 276 meals per day.

Failure to maintain sanitary practices during the meal preparation could potentially result in contaminated patient food.

Findings include:

1. Review of the CAH policy, "Infection Control-Nutrition Services" revised 12/09, stated in part, "...Careful hand washing by personnel is of prime importance in disease control...Employees should wash their hands...between handling of dirty equipment..."

Review of the CAH policy, "Staff Development and Education-Nutrition Services" revised 12/09 revealed in part, "...new employees will receive instruction and demonstrate competence in...proper handling of food...general food service safety and sanitation...proper methods of waste disposal..."

2. Review of an in-service report, "Hand washing and Glove use" dated 6/24/09 revealed in part, "...wash my hands...removing garbage...after touching anything that might result in contamination of hands...replace or change gloves...always change gloves if the gloves get...contaminated..."

3. Review of the ServSafe training proved to all dietary personnel noted in part, "...ServSafe training will provide knowledge...proper food handling practices...designed to educate all food handlers on food safety basics..."

4. During an observation on 3/30/11 at 8:20 AM, Staff J, dietary cook, tore off the plastic wrap from a package of ground steak with gloved hands. Staff J walked to the garbage can lifted the lid with his/her gloved left hand and threw away the plastic ground steak wrapper. Staff J walked back to the counter and picked up the unwrapped ground steak with his/her left contaminated gloved hand and proceeded to break up the meat into small pieces.

Staff J picked up the second package of ground steak with the contaminated gloved hands and proceeded to take off the plastic wrap. Staff J walked to the garbage can lifted the lid with the contaminated left gloved hand and threw away the ground steak wrapper. Staff J walked back to the counter and picked up the unwrapped ground steak with his/her contaminated left hand. The Dietary Director stopped Staff J and instructed Staff J to wash their hands and change gloves.

Observation on 3/30/11 at 11:10 AM, showed a digital thermometer with a stretch cord lying on the counter without a barrier. Staff J picked up the thermometer and used it to take the temperature of the food. Staff J reached across the steam table to take the temperature of the mashed potatoes and allowed the cord from the temperature probe fall into the gravy. Without cleaning the cord, Staff J reached across the mashed potatoes to take the temperature of the vegetables and allowed the cord to fall into the mashed potatoes.

5. During an interview on 3/30/11 at 8:20 AM, the Dietary Director stated, "[Staff J] should have removed gloves and washed [his/her] hands before touching the meat. [Staff J] should have used the foot pedal to lift the garbage lid."

During an interview on 3/30/11 at 2:20 PM, Staff I, Dietitian, stated, "The cord to the temperature probe shouldn't touch the food, it would not be considered clean."


22898


III. Based on observation, administrative staff interviews, and policy review, CAH staff failed to maintain 2 of 2 ice machines in patient care areas in a clean and sanitary manner in accordance with CAH policy. The CAH administrative staff reported a census of 14 patients.

Failure to routinely clean ice machines in patient care areas could potentially result in contamination of the ice used by patients, staff, and visitors.

Findings include:

1. Observation on 3/29/11 at 11:37 AM, with Staff B, Manager of medical/surgical unit, revealed the ice machine in the 2 west medication room had a moderate amount of rust build-up on the inside ceiling.

Observation on 3/29/11 at 10:40 AM, with Staff H, Director of Hope Harbor, revealed an ice machine in the north hall storage room. The ice machine had a brownish, sticky substance on the drainage tray and around the ice dispensing port. The ice machine had 4 vents that were dusty.

2. During an interview on 3/30/11 at 11:30 AM, Staff B stated the nursing personal on the medical/surgical unit do not clean the ice machine. Patient, staff, and visitors use the ice.

During an interview on 3/29/11 at 10:50 AM, Staff H stated ice from the ice machine was available for patient use. Staff H did not know who cleaned the ice machine or when staff last cleaned it.

During an interview on 3/30/11 at 9:00 AM, Staff A, Director of Plant Operations, stated the maintenance staff did not clean the ice machines.

3. Review of a policy titled "Ice Machines" (revised 4/10) on 3/30/11, revealed, in part ..."Plant Operations department will be responsible for routine cleaning and maintenance of ice machines, both dispenser and bin types, in patient care areas ....Ice machines are cleaned and sanitized at a minimum every 6 months ... "

I. Based on document review, policy review, and staff interview, the Dietitian failed to provide documented evidence of approval of the CAH menus. The CAH administrative staff reported a census of 14 patients. The Dietitian reported the dietary staff provided approximately 276 meals per day.

Failure to provide documented evidence of the Dietitian's approval of the menus could potentially result in patients not receiving the correct diet and/or their required nutrients.

Findings include:

1. Review of the policy, "Menus", revised 12/09 stated in part, "...general cycle menus shall be...approved by the dietitian...The dietitian will review and approve all menus prior to their implementation..."

2. Review of the Job Responsibilities for Nutrition Services Staff revised 12/09 stated in part, "...Registered Dietitian...approved all menus..."

3. Review of the menus lacked evidence the Dietitians approved the meals for the CAH patients.

4. During an interview on 3/30/11 at 9:20 AM, Staff I, Dietitian, stated, "I don't sign anything; I never have had to sign the menus before." Staff I stated the two Dietitians make menu changes as needed and approve the menus verbally to the dietary supervisor.

II. Based on document review and staff interview, the Dietary Staff failed to ensure the Medical Staff approved the Diet Manual updates.

The CAH administration reported a census of 14 patients. The Dietitian reported the dietary staff provided approximately 276 meals per day.

Failure to ensure the Medical Staff approved the updates to the Dietary Manual could potentially result in diet adjustments without Physician knowledge.

Findings include:

1. Review of the CAH policy, "Therapeutic Diets" revised 2/11 revealed in part, "...A diet manual adopted by the registered dietitian and approved by the medical staff she be used for all therapeutic diets...approved by the medical staff annually...."

2. Review of the current Nutritional Care manual stated in part, "...content release date: October 4, 2010...2010 updated summary..."

3. Review of the Medical Staff meeting notes revealed on 2/12/07, the Medical Staff approved the Dietary Manual. The Medical Staff meeting notes lacked the approval of the Nutrition Care Manual copyright date of 2010.

4. During an interview on 3/30/11 at 2:20 PM, Staff I, Dietitian, confirmed the dietary staff use the Nutrition Care Manual with the copyright date of 2010. Staff I stated the Medical Staff do not approve the Nutritional Care Manual or the updates annually.

Based on policy review and administrative staff interview, the administrative staff failed to ensure the required group of professionals reviewed all patient care policies annually in accordance with the regulation. The CAH administrative staff reported a census of 14 patients.

Failure to annually review all patient care policies and procedures could potentially result in obsolete, unnecessary, and inaccurate policies available for use in the CAH.

Findings include:

1. Review of the policy on 3/21/11, titled "Professional Advisory Committee (PAC)" , revised 4/2010, states in part ..." Policy Development/Review 1. The PAC monitors and assures the annual review of organizational patient care policies. 2. Patient care policy development and review is conducted by department-specific Medical Directors and department managers, and/or BVRMC (Buena Vista Regional Medical Center) Administration and staff and facilitated by the Policy Review Committee. 3. Members of the BVRMC Medical Staff are provided an opportunity to review and provide input on new patient care policies and those policies in need of revision. 4. Annual policy review may also be conducted as a function of other BVRMC Committees, under the direction of the Medical Director for the Service (i.e.: Infection Control Policies may be revised/developed under the direction of the Infection control Medical Director) ..."

2. During an interview on 3/31/11 at 10:20 AM, Staff C, Director of Quality stated the Medical Staff reviews policy revisions annually and that new policies and policies with no changes are not reviewed. The Medical Staff Bylaws did not specifically address the review of policies and procedures or the revision of policies and procedures.

Based on observation, policy review , and administrative staff interview, staff failed to secure discarded confidential patient information prior to shredding in the west maintenance shop. The CAH administrative staff reported 7 of 7 maintenance staff collect discarded confidential patient information to be shredded.

Failure to secure patient's medical records could potentially result in access to patient information by unauthorized users.

Findings include:

1. Observation on 3/29/11 at 8:43 AM, with Staff A, Director of Plant Operations, and Staff C, Director of Quality, revealed 8 large blue bags with a cinch type closure filled with discarded confidential patient information in the west maintenance shop. Staff A stated that the blue bags were collected throughout the hospital by the maintenance staff, transported to west maintenance shop, and a contracted company would shred the papers onsite.

Maintenance staff does not have a need to know the information contained in the confidential patient record.

2. Review of a policy titled "Record Retention," (revised on 5/02) on 3/20/11, stated in part ... "Purpose - The purpose of this policy is to define the proper storage, retention period and means of destruction for several types of health system records in accordance with federal and state laws and regulations. Proper storage and destruction of records serves to safeguard assets, maintain patient and employee confidentiality, ensure efficient access to stored materials, and provide for appropriate destruction of sensitive and outdated records ...Off-site Destruction of Records - Ensure records are stored in a secure location when holding for a vendor to pick up..."

3. During an interview on 3/29/11 at 8:43 AM, Staff A stated only maintenance staff have access to the west maintenance shop, 7 of 7 maintenance staff transport confidential patient information to the holding unit in the west maintenance shop.

Based on record review and staff interview the administrative staff failed to ensure delineation of privileges, specific to the hospital for 3 of 5 surgeons providing laparoscopic and arthroscopic surgeries. The Interim Surgical Care Coordinator reported the surgeons perform 14 laparoscopic and 12 arthroscopic surgical procedures a month.
Failure to ensure delineation of privileges for the surgeons performing laparoscopic and arthroscopic procedures could potentially result in unauthorized individuals performing surgical procedures that could put the patient at risk for surgical complications.
Findings include:
1. Review of the surgeon's files in the Surgery Department revealed a document titled "Delineation of Medical Privileges Desired" that showed delineation of surgical privileges in each surgeon's file.

2. Review of Surgeon L's "Delineation of Medical Privileges Desired" for 2009 showed the Medical Staff failed to include arthroscopic knee surgery in the surgeon's delineation of privileges. Surgeon L had performed arthroscopic knee surgeries at the CAH.

3. Review of Surgeon P's "Delineation of Medical Privileges Desired" for 2009 showed the Medical Staff failed to include laparoscopic cholecystectomy in the surgeon's delineation of privileges. Surgeon P had performed laparoscopic cholecystectomies at the CAH.

4. Review of Surgeon Q's "Delineation of Medical Privileges Desired" for 2010 showed the Medical Staff failed to include laparoscopic cholecystectomy and cesarean section in the surgeon's delineation of privileges. Surgeon Q had performed laparoscopic cholecystectomies and cesarean sections at the CAH.

5. Review of the CAH policy titled "Credentialing Procedures for Medical Staff and Licensed Independent Practitioners", revised 6/10, revealed in part... "Upon successful approval for additional privileges, notice is provided to the applicant and arrangements are made with the relevant department for implementation of the new privilege. Performance of new privilege is monitored through On-going Professional Practice Evaluation to validate competency."
6. During an interview on 3/31/11 at 7:05 AM, Staff C, Executive Director of Quality stated the 3 surgeons did not have complete privileges located in their files in the surgery department. The CAH staff had been working on updating privileging forms and the specific privileges requested by surgeons L, P, and Q did not get completed.

Based on review of policies/procedures, documentation, and staff interview, the administrative staff failed to include all practitioners that provided care and services to the CAH patients in their external peer review process for 15 of 23 applicable practitioners. (Practitioners A through O) The CAH administrative staff identified 306 members of the medical staff.

Failure to insure all medical staff members received external peer review could potentially expose patients to inappropriate medical care.

Findings include:

1. Review of credential files on 3/31/11 at 11:00 AM revealed the following:

a. Teleradiologist A's credential file lacked documented evidence of an external peer review.

b. Teleradiologist B's credential file lacked documented evidence of external peer review.

c. Teleradiologist C's credential file lacked documented evidence of external peer review.

d. Teleradiologist D's credential file lacked documented evidence of external peer review.

e. Teleradiologist E's credential file lacked documented evidence of external peer review.

f. Pulmonologist F's credential file lacked documented evidence of external peer review.

g. Pulmonologist G's credential file lacked documented evidence of external peer review.

h. Emergency Room (ER) H's credential file lacked documented evidence of external peer review.

i. Emergency Room (ER) I's credential file lacked documented evidence of external peer review.

j. Emergency Room (ER) J's credential file lacked documented evidence of external peer review.

k. Emergency Room (ER) K's credential file lacked documented evidence of external peer review.

l. Surgeon L's credential file lacked documented evidence of external peer review.

m. Surgeon M's credential file lacked documented evidence of external peer review.

n. Surgeon N's credential file lacked documented evidence of external peer review.

o. Physician Assistant O's credential file lacked documented evidence of external peer review.

2. Review of the CAH's policy "Credential Procedure for Medical Staff and Licensed Independent Practitioners," revised 6/10, revealed in part... "Data used in the on-going professional practice evaluation may be acquired through the following means: c. external peer review."

3. During an interview on 3/31/11 at 11:00 AM, Staff C Executive Director of Quality, stated the CAH did not complete external peer review for family practice physicians, teleradiologists, emergency room physicians and other practitioners that lacked documented evidence in the credential files that the external peer review was completed.

I. Based on document review and staff interviews the administrative staff failed to ensure the Activity Designee completed a State approved training course or supervised by qualified professional. The CAH administrative staff reported a census of 3 skilled patients and a daily average of 3-4 patients.

Failure to ensure the Activity Coordinator completed a State approved training course could potentially result in staffs failure to employ activities that meet each patients individual interests, physical, and mental needs in order to improve their psychosocial well-being and enhance recovery.

Findings include:

1. Review of the CAH Position description, "Activity Director and Activities Staff Designee", stated in part, "...Must meet the requirements of education/training as stated in Medicare skilled care/swing bed..."

2. Review of the CAH policy, "Activities Program" revised 11/10 stated in part, "...The activities program is directed by a qualified professional who...is a qualified therapeutic recreation specialist...2 years experience in social or recreational program within the last 5 years...oKupational therapist...has completed a training course approved by the state of Iowa..."

3. During an interview on 3/29/11 at 1:45 PM, the Activity Designee confirmed the hospital had not provided the required formal Activity Designee training. The Activity Designee was not aware a qualified professional needed to evaluate or cosign the activity assessment and/or plan of care for the skilled patients.

During an interview on 3/30/11 at 10:00 AM, the Chief Nursing Officer (CNO) confirmed the Activity Designee had not had the formal training required for the position of Activity Designee. The CNO stated the Recreational Therapist should be working with the Activity Designee, "But I see this is not being done."

II. Based on observation, staff, and patient interviews the Critical Access Hospital Activity Designee failed to develop and maintain an activity calendar for swing bed patients. The CAH administrative staff reported a census of 3 skilled patients and a daily average of 3-4 patients.

Failure to maintain a calendar of activities could potentially result in CAH staffs failure to implement scheduled activities designed to improve the swing bed patient ' s physical, mental and psychosocial well-being.

Findings include:

1. Observation on 3/29/11 at 2:30 PM revealed, the Medical/Surgical nursing unit and swing bed patient rooms 246 and 251 did not have an activity calendar displayed.

2. During an interview on 3/29/11 at 2:45 PM, Patient #12 stated the CAH staff visited frequently but was not aware who the Activity personnel were. Patient #12 stated staff visited but was not sure who may have been an activity person.

During an interview on 3/29/11 at 2:30 PM, Patient #13 was not aware of the name or the activity person. Patient #13 could not remember if any staff had offered any activities at this time.

During an interview on 3/29/11 at 1:45 PM, the Activity Designee confirmed there was no Activity calendar created for the swing bed patients. The Activity Designee stated an activity calendar was not created because there were not always skilled patients in the hospital.

During an interview on 3/30/11 at 10:00, the Chief Nursing Officer stated the activity designee should create an activity calendar and display the calendar in the swing bed patient rooms.

III. Based on document review and staff and patient interviews the Activity Designee failed to provide ongoing meaningful activities specific to the individual needs of the swing bed patients. The CAH administrative staff reported a census of 3 skilled patients and a daily average of 3-4 patients.

Failure to provide ongoing meaningful activities could potentially result in a lack of improvement of the patient physical, mental and psychosocial well-being.

Findings include:

1. Review of the policy, "Activities Program-skilled Care Swing Bed" revised 11/10 stated in part, "...provision is made for ongoing programs of meaningful activities...plans and conducts individual and group activities...planned activities oKur within the context of each skilled care/swing bed client's care plan...activities are in keeping with client's lifelong interests...activities can oKur at any time..."

2. Review of the CAH Position description, "Activity Director and Activities Staff Designee", stated in part, "...demonstrates flexibility in scheduling..."

3. During an interview on 3/29/11 at 1:45 PM, the Activity Designee stated there were no planned activities in the evening and/or weekends. The Activity Designee stated he/she visited the skilled patients Monday through Friday during the day hours. The Activity Designee stated the CAH staff could provide evening and weekend activities, but staff did not document the activities provided.

During an interview on 3/30/11 at 10:00 AM, the Chief Nursing Officer stated, "We need to work on this to assure activities are offered at the patient convenience not just during the Activity persons working hours."

IV. Based on document review and staff and patient interviews the Activity Designee failed to participate as a member of the multidisciplinary team on the formulation of an individualized care plan in accordance with the Activity Director and Staff Designee position description. The CAH administrative staff reported a census of 3 skilled patients and a daily average of 3-4 patients.

Failure to participate as a member of the multidisciplinary team to formulate an individualized care plan could potentially result in not meeting the individualized activity needs of the swing bed patient.

Findings include:

1. Review of the CAH Position description, "Activity Director and Activities Staff Designee", stated in part, "...participates as a member of the multidisciplinary team on the formulation of the plan of care for each patient...contributes to the...activity development."

2. During an interview on 2/29/11 at 1:45 PM, the Activity Designee reported that he/she did not attend the Interdisciplinary team meetings to develop and implement an individualized activity plan of care.

During an interview on 3/30/11 at 1:15 PM Staff K, Registered Nurse-Care Coordinator, confirmed the Activity Designee completed the skilled patient's activity assessment and care plan without the help of the Interdisciplinary team. Staff K confirmed the Activity Designee did not contribute to the individualized care plan formulated at the Interdisciplinary team meeting.