HospitalInspections.org

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on observation and staff interview, the hospital failed to maintain a preventive maintenance program to ensure equipment and supplies are maintained in a safe operating condition.

Findings included:

-Requests for the hospital Master list of Equipment revealed the hospital maintained only a list provided to them by a contracted for Bio-Medical equipment only.

Observation of the patient disposable bathing cloth kit warmer on 2/1/10 at 10:30am, revealed the machine shaking and noisy. The maintenance check sticker on this piece of equipment was dated 1/01. Administrative staff member R verified the preventive documentation on the machine was dated as completed in 2001.

Interview with Staff member A, on 2/3/10 at 11:05am revealed the hospital failed to maintain a master list of electrical and patient care equipment for Bio-Medical equipment. They verified staff were directed to bring equipment to them for electrical testing and inspection upon initial entry into service at the hospital. Maintenance tested new equipment, but did not list the equipment for tracking, and performed random spot checks on the equipment after that. Maintenance stated the initial check of the equipment depended upon the receiving staff bringing it to their attention, and verified that did not always happen.

The hospital identified a census of 4 patients. Based on observation, document review, and staff interview, the hospital failed to ensure drugs were appropriately stored.

Findings included:

- Review of the hospital policy titled "Storage of Medications", last revised 8/09, directed staff that Schedule 3, 4, and 5 medications could be out on the shelf in the main drug room in an unlocked cabinet.

The Regulations for Kansas State Hospitals, KAR 28-34-10a(c)stated-"...Drugs and biologicals must be kept in locked storage areas..."

Tour of the Laboratory, on 2/1/10 at 11:40am revealed the department had an unlocked area with a manufacturers foil unit dose pack which contained 5-10 milligrams (mg)Phenylephrine tablets and 1 bottle of approximately 60 each of 64 mg Slow Mag Magnesium Chloride tablets.

Tour of the Emergency and Outpatient Department, on 2/1/10 at 1:50pm revealed multiple unlocked, unattended medications and biologicals which included: 1-20 milliliter (ml) bottle of Lidocaine Injection 1%-10 mg/ml, 2 bottles of Diphenylcyclopropenone in Acetone, Dexamethasone injectable-4 mg/ml-5 ml bottle, Kenalog Injectable 40 mg/ml -10 ml. bottle, Lidocaine 2%-20 ml. bottle, Lidocaine 1%-20 ml. bottle, Marcaine 0.5%-30 ml. bottle, 1 tube Lidocaine jelly 2%. Interview with Licensed staff member K, on 2/1/10 at 2:10pm verified the staff stored the medications in the unlocked and unattended areas in the Emergency Department and Outpatient Area.

Tour of the Radiology Department, on 2/1/10 at 12:10pm revealed an unlocked cabinet in the unattended room which contained 3 ampules of Lidocaine 1% Injectable.

Observation on 2/3/10 at 7:30am in the nursing unit revealed 2 unit dose tablets of Zofran, unattended, on top of the medication cart. Interview with nursing staff U at 7:35am reported the medication should be locked in the medication cart and not left out.

The facility failed to instruct staff and ensure all medications are secured as required.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on observation, document review and staff interview, the hospital failed to ensure the premises and all patient care equipment remained clean and orderly in the Laboratory, Radiology, Emergency Department, and 9 of 16 patient rooms. (105,106,107,108,109,116,118,120,and 122)

Findings included:

- Tour of the waiting room between the Laboratory and Radiology, on 2/1/10 at 11:30am revealed gouged areas in the walls exposing the drywall which measured 18 feet long by 2 inches wide on the west side and 12 foot long by 2 inches wide on the east side and 1-2 foot long by 2 inches wide areas on both sides of the waiting room.

Tour of the Emergency Department (ED), between 8:15am and 8:30am revealed the Special Procedure Room and the ED trauma room contained open Yankauer suction catheters. Administrative Nurse J revealed they did not know how long this equipment had remained open to potential contamination in this room.

Tour of the Radiology Department, on 2/1/10 at 11:53am revealed a Yankauer suction catheter completely out of the package. Licensed staff member L, verified the catheter had been opened for at least 1 week.



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- Observation on 2/1/10 at 10:00am in patient care room 105 revealed 6 quarter size gouges in the wall at the head of the recliner with sheetrock exposed. Room 107 revealed a foot long wall gouge near the arm of the recliner with sheetrock exposed. Room 109 revealed a dime size gouge on the wall at the head of the bed near the recliner and 2 pea size gouges near the arm of the recliner with exposed sheetrock. Rooms 108, 116, 118 and 120 also had gouges on the walls with exposed sheetrock.

Interview with maintenance staff A on 2/3/10 at 11:05am revealed the hospital lacked any work orders to repair the walls. Staff A stated the hospital environmental rounds noted the gouges and that they were aware but lacked a plan to repair them.

- Observation on 2/1/10 at 10:00am in patient care room 107 revealed the grab bar next to the toilet had a pea size build-up of dark brownish stain. Room 108 revealed 30% of the bar had a build-up of dark brownish stains. Rooms 105,106 and 122 also had a built-up of dark brownish stains on the grab bars in the bathrooms.

Interview 2/3/10 at 11:00am with housekeeping staff N revealed the staff removed the grab rails and attempted to clean the dark stains and re-hung the bars. Staff N reported they were aware the bars "looked bad" and stated the hospital did not have a plan to replace the bars.

- Observation on 2/1/10 at 10:15am in patient care room 105 revealed housekeeping staff T cleaning the room. Staff T sprayed the mattress with a cleaner, which revealed a dark stain that covered 60% of the mattress cover. Staff T reported they have attempted to clean the mattress with multiple cleaners but nothing has worked. Interview 2/3/10 at 11:00am with housekeeping staff N stated they were aware of the stained mattress and also reported the use of multiple cleaners that failed to remove the stain. Staff N stated the mattress covers are not cleanable and will need to be replaced.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on document review and staff interview the hospital failed to develop an appropriate plan for access to emergency fuel and water.

Findings included:

- Review of the hospital policy for "Utility Failure", last revised on 8/17/05 documented instruction to staff as follows:"...WATER FAILURE: Take conservative measures immediately. Use the bottled water for consumption purposes only. NATURAL GAS FAILURE: Kitchen and laundry personnel will need to plan accordingly..."

Interview with staff member A, on 2/3/10 at 11:05am verified this policy and procedure as the only direction provided to staff for these types of emergencies. They further verified the hospital lacked stores of bottled water, did not have a contract to have this provided to them in the event of an emergency, and failed to plan for amounts of fuel and water needed for emergencies.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on document review and staff interview, the governing body failed to ensure credentialing was completed accurately for 6 of 8 staff (B, D, E, F, G, H), and failed to recredential 1 of 8 staff to reflect the physician's correct practice status (C).

Findings included:

- Review of the Governing Body bylaws, last reviewed 8/24/92, revealed the Governing body required the Medical Staff to make recommendations to the Board for its approval regarding Physician Credentialing.

Review of the Medical Staff Bylaws, last amended and revised in 2005, Section 4.7-4 stated the facility would request information about the initial applicant from the National Practitioner Data Bank and the Cumulative Sanction Report produced by the Department of Health and Human Services Office of Inspector General shall also be checked for any reference to the applicant. The Bylaws further stated the hospital would consider past or present malpractice suits or claims, but failed to direct staff to query the National Practitioner Data Bank or the Office of the Inspector General for consideration prior to reappointment.

Review of the hospital Credentialing, on 2/3/10 at 1:30pm revealed the Governing Body recredentialed physician A on 5/19/08 based on National Practitioner Data Bank (NPDB) information from 4/28/06, Physician's D and F on 4/28/08 on NPDB information dated 5/1/06, and Physician E on 4/28/08 on NPDB information from 9/20/06. The review also revealed the hospital failed to query the NPDB for Mid-Level Practitioners G and H. Interview with staff I, on 2/3/10 at 1:45pm verified the hospital failed to query the NPDB prior to re-credentialing of the Physicians because "We decided we didn't need to do that", and further stated the hospital did not ever query the NPDB prior to credentialing the Mid-Level Practitioners, and also did not have any Delineation of Privileges for the Mid-Level Practitioners.

The Medical Staff Bylaws, section 5.4, further stated Locum tenens privileges may be granted initially for a maximum period of 60 days and may be renewed for additional 60 day periods.

Review of the hospital Credentialing revealed the hospital approved Physician C for Locum Tenens status on 7/23/07 and failed to obtain application and approval for this physician to change to Active status. The Medical Staff Roster provided during the survey identified this physician as active staff. Interview with staff I, on 2/3/10 at 1:45pm verified this hospital failed to obtain information and change this physician's status to Active.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on document review and staff interview the Critical Access Hospital failed to ensure a mid-level practitioner assisted in the development and review of the hospitals policies.

Findings included:

- Requested documentation of the hospital's mid-level practitioner staff involvement in the development and review of the policies from administrative staff J on 2/2/10 at 10:00am and the hospital failed to provide.

On 2/4/10 at 11:30am administrative staff P provided a copy of the nursing manual's signature review sheet. Staff P reported the nursing manual is the only hospital service manual reviewed by the mid-level practitioner. Staff P reported the hospital failed to ensure a mid-level practitioner reviewed the hospital wide services policy manuals.

The hospital identified a census of 4 patients with 38 medical records chosen for review. Based on document review and staff interview the Critical Access Hospital failed to establish a group of professionals to develop policies for the hospital with at least one person not a member of the Critical Access Hospital staff.

Findings included:

- Requested meeting minutes of the group of professionals on 2/2/10 from administrative staff J at 9:00am and on 2/3/10 at 10:00am from administrative staff I and the hospital staff failed to provide the minutes.

Interview on 2/4/10 at 9:00am with administrative staff P reported the hospital lacked meeting minutes and failed to develop a group of professionals with a non-member of the hospital to review the policies.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on observation, document review and staff interview, the hospital failed to ensure outdated drugs and biologicals not available for patient use in the Emergency Department, Outpatient Department, Radiology and Laboratory.

Findings included:

- Review of the facility policy titled Outdated Medication, last revised 7/02, stated "...3. Drugs at the nurse's station, OR (Operating Room), OB (Obstetrics), and the ER (Emergency Room) are checked on a monthly basis by the nurses working in those areas..." This policy further stated that the Hospital Pharmacy checked all of those areas quarterly to ensure proper storage and check for outdates.

Tour of the hospital laboratory on 2/1/10 at 10:50am revealed 1 bottle of Chemistry H Control solution which expired on 12/31/07 and 4 bottles of A1C calibration solution which expired 8/14/07. The Laboratory also contained 10 Liquicheck Qualitative Urine Toxicology Controls which expired on 8/31/08, 1 bottle of Protocol Hema3 Solution 1 which expired on 9/09, 1 bottle of Protocol Hema3 solution 2 which expired on 8/09 and 1 bottle of Peroxide which expired on 6/08. Laboratory staff member V, on 2/1/10 at 11:10am stated that no one in particular was assigned to check for outdates, and verified staff should have pulled the expired items from the area.

Tour of the Emergency Department (ED), on 2/2/10 at 8:15am revealed a cabinet adjacent to the ED contained a bottle of Kenalog Injectable Medication and Lidocaine Injectable medication, both of which were opened and not dated. This area also contained a bottle of Marcaine 0.5 % injectable medication, which stated "single dose vial preservative free". This vial displayed evidence of being opened and previous entry into the bottle. Staff returned this medication to the tray for future use on patients. The Outpatient area also contained 2 bottles of Diphenylcyclopropenone in Acetone labeled as "expires in 1 year" and the hospital dated the bottle as mixed on 10/8/07. This area also contained 2 bottles of Cantharidin Topical 1% solution which one stated to discard after 9/15/09 and the other stated to discard after 11/29/07. Two small bottles labeled as Pre-tape stated to use before 4/09. The examination room adjacent to this area also contained a large 32 ounce bottle of the Pre-tape which documented expiration on 4/09.

Tour of the Radiology Department, on 2/1/10 at 11:53am. revealed the Computerized Tomography (CT) room contained 18 different sizes of Intravenous Cathlons which expired between 9/2007 and 11/2009, 2 bottles of Povidone/Iodine solution which expired on 7/2008 and 11/2008. Licensed staff member L, at that time, stated that all of the staff in the Department had the responsibility to check for outdates.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on document review and staff interview the Critical Access Hospital failed to ensure the infection control officer followed their established program policies, failed to develop and maintain a infection control committee, failed to monitor and track employee health and infections, failed to monitor infection control practices, failed to identify and control exposure to infection at the hospital.

Findings included:

- Review of the Infection Control Program Plan dated 6/2/97 revealed the plan would include a infection control program, infection control committee and be active in developing policies.

The program plan stated "There shall be an active hospital-wide Infection Control Program....Effective measures must be developed to prevent, identify and control such infections...Review infection control policies at least yearly and revise. "

Review of the Infection Control data on 2/3/10 revealed the infection control officer maintained a infection log with the patients name, date of service, area with the infection, type of organism and if antibiotics were used. The log revealed the hospital had 75 inpatient infections, lacked evidence of any employees infections and lacked identification of any community acquired infections. The infection control data lacked evidence of trending, surveillance and monitoring for infections.

Interview on 2/3/10 at 4:30pm with Infection Control staff K revealed the hospital tracked hospital acquired infections on a log. Staff K reported they collected the patient infection data from open and closed medical records one day a week. Staff K reported they do not track or trend the infections, lacked knowledge of their hospital wide infection rate, do not perform any infection control surveillance, do not include employee health and do not include other departments in the infection data.

Review of the infection control documentation lacked evidence of the last policy review. Interview on 2/3/10 at 4:30pm with Infection Control staff K reported they assumed the infection control position four years ago and the policies have not been reviewed annually.

Review of the infection control plan revealed the hospital will develop a infection control committee with members from the laboratory, maintenance, surgery, respiratory therapy, medical records, risk management, safety and the infection control nurse. The plan stated the infection control committee will maintain meeting minutes. Review of the infection control information lacked evidence of an established committee, lacked evidence of any meeting minutes and lacked evidence of departmental reports to the infection control officer.

Interview on 2/3/10 at 4:30pm with Infection Control staff K reported the hospital failed to develop a infection control committee and lacked any meeting minutes for review.

Review of the infection control plan stated the infection control policies will be reviewed and revised based on the observed practices at the hospital. The plan stated "benefits of a surveillance program for hospital infection...continuous emphasis at all levels of the hospital staff on the necessity for scrupulous observance of the fundamentals of both personal and hospital hygiene".

Review of an interpretation by the Occupational Safety and Health Administration (OSHA), dated 4/21/1992-Eating and drinking in area where potentially infectious material exists, instructed "...This regulation prohibits the consumption of food and drink in areas...where the potential for contamination of work surfaces exists..."

Review of the hospital Environmental rounds/safety inspections dated 3/10/09 and 10/14/09, the facility included in the rounds the expectation that "...No food or drink in patient care areas; unless in spill proof container..."

Tour of the Laboratory, on 2/1/10 at 10:50am and again at 11:20am revealed multiple cabinets and drawers, in the clinical part of the Laboratory which contained a styrofoam cup of pop with the drinking spout open, a can of soup, a donut and a honey bun, a small candy bar, and multiple packets of ketchup and mayonnaise. Interview with Laboratory staff member V, on 2/1/10 at 11:40am verified staff were not supposed to keep drinks and food in the Laboratory.

Tour of Radiology, on 2/1/10 at 11:52am revealed a patient X-ray room under sink counter with 2 boxes of chocolates and large can which contained 3 kinds of popcorn, the X-ray reading room (dark room) counter had 2 plastic containers, 1 which contained chocolate cookies with loose powdered sugar coating and another which contained cinnamon rolls with icing as well as a thermal lunch container with food. Another counter, directly above the lower counter which the facility used for x-ray reading and documentation had multiple drinks in various containers with their drinking spouts open allowing for spillage.

Tour of the hospital Outpatient area, on 2/1/10 at 1:50pm revealed a dirty utility room with a flushing rim sink. This area failed to have gowns or face protection by it. Licensed staff member W, at that time, stated in regards to the Personal Protective Equipment (PPE)-"it must have disappeared."

Further tour of the hospital on 2/1/10 at various times revealed flushing rim sinks in the soiled utility room next to the Birthing room, and the Soiled Utility room across from the patient rooms. The hospital also maintained a high pressure spray wand in 16 patient bathrooms. The hospital failed to provide all PPE needed to protect staff from potentially contaminated spray in these areas.

Interview on 2/3/10 at 4:30pm with Infection Control staff K revealed they do not perform any infection control surveillance of staff and infection control practices.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on document review and staff interview the Critical Access Hospital failed to establish a group of professionals to develop and review hospital policies annually.

Findings included:

- Documentation was requested twice for the hospital annual policy review conducted by the group of professionals. On 2/2/10 at 9:00am, administrative staff J and on 2/3/10 at 10:00am, administrative staff I failed to provide documentation of the hospital's annual policy review.

Interview on 2/4/10 at 9:00am with administrative staff P reported the hospital lacked documentation of an annual policy review by the group of professionals.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on document review and staff interview the hospital failed to ensure 3 hospital physicians (D, E, C) promptly completed their medical records.

Findings included:

- Review of the Medical Staff Rules and Regulations, 4.1-COMPLETE RECORD REQUIRED, dated 7/19/2005, documented the hospital "...would maintain a medical record for each patient that is...complete..." The Rules and Regulations further stated that the medical record would be considered delinquent "4.2(a)(ii)...if all chart elements are not completed within 30 days of discharge..."The rules and regulations, at section 4.2(d) further stated "...The Medical Staff Bylaws, Section 10.2 provides for a limited suspension in the form of the withdrawal of admitting and other related Clinical Privileges until medical records are completed..."

Review of the hospital delinquent records revealed Physician D with the medical record for patient #39, delinquent since 12/24/09, patient #40 delinquent since 10/15/09, patient #41 delinquent since 12/18/09, patient #42 delinquent since 1/8/10, and patient #43 delinquent since 8/28/09-greater than 5 months delinquent.

Review of the hospital delinquent records revealed Physician E with the medical record for patient #44 delinquent since 11/31/09, patient #45 delinquent since 11/28/09, patient #46 delinquent since 1/21/10, patient #47 delinquent since 8/21/09-greater than 5 months, and patient #48 delinquent since 7/10/09-greater than 6.5 months.

Review of the hospital delinquent records revealed Physician C with medical records for patient #45 delinquent since 11/28/09, patient #41 delinquent since 12/18/09, and patient #49 delinquent since 12/13/09.

Medical Records staff member S, on 2/2/10 at 1:45pm verified the medical records as delinquent and stated the physician came in every week to the hospital, verified medical records made the delinquent records available to the physician for completion, but the physician failed to complete the medical records for several months.

Staff member O, on 2/2/10 at 2:30pm verified knowledge of the multiple delinquent records by a couple of hospital physicians and stated that for a period of time it was their responsibility to get the records signed when the physicians came to the hospital. Staff O reported one Physician stated they did not want the Operating Room Nurses "hounding" them about records and stated it "was a medical records issue." This staff member further stated this happened about 4 months ago and Physician E informed Staff member O they would sign the records when they were ready. Staff member O stated they informed the Director of Nurses, Administrator, and the Medical Records Director of Physician E's comments.

Interview with facility Administrative Nurse J, on 2/2/10 at 2:45pm acknowledged problems with delinquent records and reported the physician's were reluctant to complete them timely and further stated "I have no pull when it comes to these Surgeons..."

Interview with Administrative staff R, on 2/2/10 at 5:42pm stated they call the physician's about their delinquent records, and further stated that if the hospital terminated their privileges they will not have a surgeon.

During review of the Physician Credentialing for these 3 physician's revealed the lack of any delinquent record notices.

Interview with Administrative staff member R, on 2/3/10 at 2:20pm stated they thought letters were sent to the Physician's regarding the need to complete their delinquent records, but verified lack of written documentation of this and now stated everything was done verbally.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on document review and staff interview the Critical Access Hospital failed to ensure the health care policies were reviewed annually during their program evaluation.

Findings included:

- Review of the Critical Access Hospital Annual Evaluation Summary for July 1, 2007 to June 30, 2008 revealed Section "V. Review of health care policies. Each department should review their policies with concerns to be brought to administration. Administration may then report at the annual review. Those departments involving patient care should also have policy and procedure manual approved by Medical Staff." The document lacked evidence of any policy review during the program evaluation.

Review of the Critical Access Hospital Annual Evaluation Summary for July 1, 2008 to June 30, 2009 revealed Section "V. Review of health care policies. Each department should review their policies with concerns to be brought to administration. Administration may then report at the annual review. Those departments involving patient care should also have policy and procedure manual approved by Medical Staff." The document lacked evidence of any policy review during the program evaluation.

Interview with administrative staff P on 2/4/10 at 11:00am reported the hospital failed to include a annual review of all health care policies with their program evaluation.

The hospital identified a census of 4 patients with 38 medical records reviewed. Based on document review, and staff interview, the hospital failed to complete Quality Assurance for areas with ongoing identified problems in Medical Records, Housekeeping, and Infection Control.

Findings included:

- Review of the hospital delinquent records revealed Physician D, Physician E, and Physician C, with multiple delinquent medical records dating back to 7/09, several months past due.

Staff member S, on 2/2/10 at 1:45pm and staff member O on 2/2/10 at 2:30pm verified knowledge of the delinquent medical records.

Administrative Nurse J, on 2/2/10 at 2:45pm and Administrative staff R, on 2/2/10 at 5:42pm also verified knowledge of the delinquent medical records.

Interview with hospital Quality Assurance staff member Q, on 2/4/10 at 8:45am verified multiple hospital staff knew of the problem with lack of timely completion of medical records, and verified the Quality Assurance tracking failed to include the Physician's with the long standing incomplete medical records.

- Tour and observation on 2/1/10 between 10:00am and 11:00am revealed gouges of the wallboard with exposed sheetrock in the following areas: the waiting room between the Laboratory and Radiology, and patient rooms 105, 106, 107, 108, 109, 116,118, 120, and 122.

Interview with maintenance staff A on 2/3/10 at 11:05am revealed the hospital lacked any work orders to repair the walls. Staff A stated the hospital environmental rounds noted the gouges and that they were aware but lacked a plan to repair them.

Observations, on 2/1/10 at 10:00am in patient care rooms 107, 108, 105, 106, and 122 contained a build up of dark brownish stains on the grab bars in the bathrooms.

Interview 2/3/10 at 11:00am with housekeeping staff N revealed the staff removed the grab rails and attempted to clean the dark stains and re-hung the bars. Staff N reported they were aware the bars "look bad" and stated the hospital did not plan to replace the bars.

Interview with Quality Assurance staff member Q, on 2/4/10 at 9:10am verified knowledge of the areas needing repair and cleaning, and reported these identified problems not addressed in Quality Assurance.

- The program plan stated "There shall be an active hospital-wide Infection Control Program....Effective measures must be developed to prevent, identify and control such infections...Review infection control policies at least yearly and revise. "

Review of the Infection Control data on 2/3/10 revealed the infection control officer maintained a infection log with the patients name, date of service, area with the infection, type of organism and if antibiotics were used. The log revealed the hospital had 75 inpatient infections, lacked evidence of any employees infections and lacked identification of any community acquired infections. The infection control data lacked evidence of trending, surveillance and monitoring.

Interview on 2/3/10 at 4:30pm with Infection Control staff K revealed they do not track or trend the infections, lacked knowledge of their infection rate, do not perform any infection control surveillance, do not include employee health and do not include other departments in the infection data.

Quality Assurance staff member Q, on 2/4/10 at 8:50am reported their Quality Assurance lacked Infection control tracking, trending, and monitoring.

The Critical Access facility reported a annual swing bed census of 637 between July 2008 and June 2009 and reported a current census of 2 swing bed residents, two open and 3 closed swing bed records were review. Based on document review and staff interview the Critical Access facility failed to ensure the swing bed residents received a complete copy of their resident's rights.

Findings included:

- Review of admission information related to swing bed rights lacked evidence of any notice of the resident's right for transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility as required at C-373.

Interview 2/4/10 with the Administrative staff P and swing bed coordinator M at 10:30am reported the facility failed to include the above information in the swing bed rights and failed to develop a policy to direct swing bed staff on the admission, transfer and discharge process.

- Review of admission information related to swing bed rights lacked evidence of any notice of the resident's right to be permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; or the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; or the safety of individuals in the facility is endangered; or the health of individuals in the facility would otherwise be endangered; or the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or the facility ceases to operate as required at C-374.

Interview 2/4/10 with the Administrative staff P and swing bed coordinator M at 10:30am reported the facility failed to include the above information in the swing bed rights and failed to develop a policy to direct swing bed staff on the admission, transfer and discharge process.

- Review of admission information related to swing bed rights lacked evidence of any notice of the resident's right of when the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (a)(2)(i) through (v) of this section, the resident's clinical record must be documented. The documentation must be made by the resident's physician when transfer or discharge is necessary under paragraph (a)(2)(i) or paragraph (a)(2)(ii) of this section; and a physician when transfer or discharge is necessary under paragraph (a)(2)(iv) of this section as required at C-376.

Interview 2/4/10 with the Administrative staff P and swing bed coordinator M at 10:30am reported the facility failed to include the above information in the swing bed rights and failed to develop a policy to direct swing bed staff on the admission, transfer and discharge process.

- Review of admission information related to swing bed rights lacked evidence of any notice of the resident's right before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section.

Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged as required at C-373.

Interview 2/4/10 with the Administrative staff P and swing bed coordinator M at 10:30am reported the facility failed to include the above information in the swing bed rights and failed to develop a policy to direct swing bed staff on the admission, transfer and discharge process.

- Review of admission information related to swing bed rights lacked evidence of any notice of the resident's right of notice may be made as soon as practicable before transfer or discharge when the safety of individuals in the facility would be endangered under paragraph (a)(2)(iii) of this section; or the health of individuals in the facility would be endangered, under paragraph (a)(2)(iv) of this section; or the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(ii) of this section; or an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a) (2)(i) of this section; or a resident has not resided in the facility for 30 days as required at C-378.

Interview 2/4/10 with the Administrative staff P and swing bed coordinator M at 10:30am reported the facility failed to include the above information in the swing bed rights and failed to develop a policy to direct swing bed staff on the admission, transfer and discharge process.

- Review of admission information related to swing bed rights lacked evidence of any notice of the resident's right of a written notice specified in paragraph (a)(4) of this section must include the following.
o The reason for transfer or discharge;
o The effective date of transfer or discharge;
o The location to which the resident is transferred or discharged;
o A statement that the resident has the right to appeal the action to the State; and
o The name, address and telephone number of the State long term care ombudsman.
o For nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act.
o For nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy for mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act as required at C-379.

Interview 2/4/10 with the Administrative staff P and swing bed coordinator M at 10:30am reported the facility failed to include the above information in the swing bed rights and failed to develop a policy to direct swing bed staff on the admission, transfer and discharge process.

- Review of admission information related to swing bed rights lacked evidence of any notice of the resident's right, a facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility as required at C-380.

Interview 2/4/10 with the Administrative staff P and swing bed coordinator M at 10:30am reported the facility failed to include the above information in the swing bed rights and failed to develop a policy to direct swing bed staff on the admission, transfer and discharge process.