HospitalInspections.org

Based on interview, record review, and policy review the facility failed to:
- Adequately assess, treat, and/or monitor one (#20) of three discharged patients reviewed in the Emergency Department (ED).
- Follow their internal policy regarding suicidal (thoughts of self-harm) prevention for one (#20) of three discharged patients reviewed in the ED.
- Follow their internal policy regarding use of restraints (devices used to immobilize a patient's arms, legs, body or head for their safety) for three (#18, #19, and #20) of three discharged patients reviewed in the ED.
- Follow their internal policy regarding use of code dialect (Missing Patient) over the loud speaker when an elopement (when an unsafe patient leaves the hospital without permission).
occurs within the hospital for one (#20) of three discharged patients reviewed in the ED.
- Provide adequate supervision to prevent one patient (#20) from elopement.
- Report internally (via an Event Report), or investigate, the elopement for one (#20) of one patient that eloped, which resulted in the failure to implement corrective action to prevent future episodes.
- Identify the use of restraints, and any adverse outcome from their use in the ED quality assessment (QA) program for three (#18, #19, and #20) of three discharged patients reviewed in the ED.
- Train ED staff and physicians on the proper and safe use of restraints for at least the prior three years. The above failures had the potential to affect all ED patients. The average ED patient visits were 182 per week. The facility census was 12.

The cumulative effect of these systemic practices had the potential to place all patients in the ED at risk for their health and safety, also known as immediate jeopardy (IJ).

As of 01/10/14, at the time of survey exit, the facility had provided an immediate action plan sufficient to abate the IJ by implementing the following:
- To make one ED bay (#3) safe for psychiatric patients by removing access to hazardous chemicals, machines, tools, looping/cutting mechanisms, etc.
- To train staff for one-on-one observation at all times for the patient assessed as being at risk for elopement, suicide or homicide. This training will recur annually.
- Develop a psychiatric patient evaluation policy, with psychiatrist review/input and approval.
- To begin restraint training for all ED staff and physicians immediately and prior to next shift assigned.
- Update policies regarding elopement, suicide prevention, and restraints.
- Review and evaluate types of restraints currently utilized in the ED.
- Utilize the "Missing Patient," code on the overhead paging system when an elopement occurs.
- Develop guidelines for psychiatric medication use and chemical restraints.
- Implement some type of behavioral, crisis prevention training for ED staff.
- All staff to receive training regarding completion of Event Reports, and their subsequent investigations.

Findings included:

1. Record review of the facility's policy titled, "Restraints," revised 06/01/08, showed the following:
-Patients have the right to be free from the use of restraints, of any form, as a means of convenience or coercion.
-A restraint does not include surgical dressings or bandages.
- Restraints used to manage behaviors is an emergency measure and increased vigilance is required because of the heightened potential for harm or injury as the patient struggles or resists.
- There is immediate need for assessment of what has triggered a behavior and for continuous monitoring of the patient's condition.
- Documentation should include least restrictive measures considered, the patient's response to the intervention, and the patient should be reassessed every 30 minutes for signs of injury, nutrition, hydration, circulation and elimination.
- Make part of the internal QAPI evaluation, patient care activities that have potential safety issues, including the use of restraints.
- Staff who have direct patient contact are trained in the proper and safe use of restraints.

Record review of the facility's policy titled, "Suicide Prevention," dated 07/07/87, showed the following:
- Patients with potential for self-injury will be identified and precautions taken to prevent same.
- Staff will inquire about prior suicidal behavior (two or more events indicate high risk).
- Watch for suspect behavior such as restlessness, recent object loss, negative feelings.
- Remove all articles easily used in self-harm such as scissors.
- Be alert when suicidal patients are using the bathroom.
- Observe acutely suicidal patients on a one-to-one basis.

2. Record review of Patient #20's ambulance record, dated 12/08/13, showed the patient admitted to taking a number of different medications in an attempt to "mix them with some alcohol and never wake up again." "The patient reports that today is the anniversary of his sister's death, and he [wants to join her])." The patient also reported, "If you let me go tonight, I'll be worse tomorrow."

3. Record review of discharged Patient #20's ED physician and Nurses' Note documentation, dated 12/08/13, showed the following:
- Patient #20 presented to the ED at 2:27 AM with complaints of suicidal ideations. The patient had already carved (with a razor blade) his sister's name, and branded it (with a clothes hanger), into his left forearm. The patient had also taken an overdose of sleeping and anti-seizure medications.
- The patient was placed in a gown and put in an ED bay (room).
- At 3:58 AM, the patient was found going through the ED bay cabinets (containing alcohol and hydrogen peroxide which could be hazardous if ingested). The contents of the cabinets were removed after, the patient was discovered going through them, even though the patient was assessed as being suicidal. (Staff failed to make the environment safe and/or provide adequate supervision of the patient).
- At 4:46 AM, the patient ran out the ED door. A hospital (not ED) staff member called the ED and told them a patient was running around outside the hospital. (Staff failed to provide adequate supervision of the patient).
- At 5:06 AM, a local nursing home (down the street about two blocks away-on a main two-lane highway) called the ED and told them the patient was in their building.
- At 5:22 AM, the nursing home called the ED again and told them the patient was still in their building (this could have created a danger to Patient #20 and/or the residents of the nursing home).
- At 5:57 AM, one hour and eleven minutes after eloping, the local police returned the patient to the ED.
- At 6:14 AM, the ED physician wrote an order to restrain the patient. (Facility staff failed to document a restraint assessment and/or document lesser restrictive measures attempted prior to the restraint application per their policy. Staff failed to document what type of restraints were used and what limbs were restrained).
- At 7:02 AM, the patient pulled his right arm out of restraints and sat up in bed. Staff failed to re-assess the type and reason for the restraint and/or document the 30 minute restraint assessment at 6:44 AM. The right arm was not re-restrained.
- At 8:10 AM, the patient was released from restraints so he could eat. Staff failed to document the 30 minute restraint assessment at 7:32 AM, at 8:02 AM.
- At 8:38 AM, the patient was seen crawling around on the ED floor trying to leave the ED without being seen. The patient was placed back in four-point restraints (both wrists and both ankles).
- At 8:49 AM, the patient had loosened the right wrist restraint so the physician documented, "I told him twice that if he didn't quit I was going to fasten him down so he couldn't. I ordered him put in a C-collar (cervical collar, a collar-type device used to immobilize the head/neck) and immobilized with wrap around his forehead and bed put up right so he could not escape as he did earlier." (This is not a typical type of restraint and can be hazardous as it can result in suffocation).
- At 8:50 AM, the patient was secured with the C-Collar and tape.
- At 1:05 PM, the patient was out of restraints again walking toward the ED door. (Staff failed to adequately supervise the patient knowing he was an elopement risk).
- At 1:15 PM, the restraints were inspected by staff and noted they had been cut. The patient admitted he had hidden trauma sheers (scissors) under the ED mattress. (Staff failed to adequately supervise the patient and remove the scissors, even though they knew he was a suicide risk. The patient could have harmed himself and/or others with the trauma sheers. Staff also failed to document (according to policy) the 30-minute restraint assessments (as directed in policy) from 10:00 AM through transfer to another acute care facility at 6:54 PM).

4. During an interview on 01/09/14 at 9:05 AM, Staff A, Registered Nurse (RN) ED Manager, stated the following:
- No ED staff (RNs or physicians) had been trained by the facility regarding restraint use for the prior three years.
-No ED staff had been trained by the facility regarding how to handle aggressive and/or psychiatric patients with behaviors for the prior three years.
- The charge nurse should have initiated an Event Report and one was not completed regarding the elopement of Patient #20. An Event Report would trigger an investigation.
- No documented, thorough, investigation had been completed regarding the elopement of Patient #20. Staff A did discover that ED staff failed to remove the trauma sheers lying on top of the crash cart in the ambulance bay where Patient #20 was located.
- A male medic left the patient alone while the patient used the restroom, and the patient retrieved the trauma shears, hid them under the mattress and used them to cut the restraints so he could elope.
- The ED used the local police to assist them in handling out-of-control patients as they had no security staff. On the day of this event, the police staff were too busy to assist them and they only had two RNs and one medic on duty at the time.
- The ED did not identify and/or track the use of restraints in their departmental QA.

5. During an interview on 01/09/14 at 1:35 PM, Staff U, ED physician, stated the following:
- He had restraint training while in residency, but none provided by the facility.
- Patient #20 was suicidal on admission and unreasonable, evidenced by not listening to staff or local police.
- Patient #20 could twist, jerk and bite his way out of the restraints, and had escaped already, so he had staff put a C-collar on the patient and secured the patient's forehead to the ED mattress using a foam-type tape, all to keep the patient safe. Staff U had never used this method of restraint before.
- Patient #20 was verbally hateful, but not physically threatening toward him, or other ED staff.

6. During an interview on 01/09/14 at 2:15 PM, Staff Y, ED RN, stated the following:
- Patient #20 came in suicidal related to the anniversary of his sister's death, whereby the patient had handled his sister's brains.
- The pole used to hang intravenous solutions was removed from the ED bay, but nothing else removed from the ED bay.
- The patient wrapped himself in a sheet and blanket, and had been pacing (signs of restlessness and potential elopement risk behaviors), so she knew the patient was getting ready to elope. He ran past the ED registration clerk, and when questioned, he said he had to run. (Staff failed to attempt elopement interventions of a suicidal patient, even though the patient exhibited risks prior to actually leaving).
- The facility had a code dialect they announced over the loud speaker ("Missing Patient") for a behavioral patient (to let other staff know they needed assistance); however, this code was not used. And, Staff Y could not remember what the code dialect policy was.
- The ED never used one-on-one staff for a psychiatric/behavioral type patient. Local police watched patients, and if they (the police) couldn't or they left, the staff prayed.
- Staff Y had brought concerns about lack of security and safety of staff to the attention of administrative staff (approximately two months prior), but had not been made aware of an investigation/resolution.
- Staff Y had no restraint training since hired approximately five years prior.
- Staff Y could not remember completing an Event Report (as charge nurse).
- Staff Y had not been questioned by hospital administrative staff regarding the event involving Patient #20 (to investigate).

7. During an interview on 01/09/14 at 2:47 PM, Staff X, ED RN, stated the following:
- Staff kept trying to get the patient to stay in the ED bay; the patient was restrained but would get out, or chew on the restraints.
- The ED was busy that night and there were only two RNs. The medic assisted the patient to the bathroom, and Staff X intended for the medic to stay with the patient, but the medic did not (allowing the patient to find and hide the scissors).
- Staff X had her head down as she was charting, and had a "feeling" so she looked up and saw Patient #20 crawling on the floor, trying to get by her so he could elope.
- Staff X had no restraint training since hired approximately five years prior.
- Staff X had not been questioned by hospital administrative staff regarding the event involving Patient #20 (to investigate).

8. During an interview on 01/09/14 at 8:55 AM, Staff L, Administrator stated that he had not been aware of the event involving Patient #20 until the surveyor brought it to his attention. Staff L stated that he would have expected the ED charge nurse to complete an Event Report, and for the ED Manager to conduct an investigation, with Risk Management and the Director of Nurses' (DON) assistance. Staff L stated that even though the DON had been aware of the event, she failed to direct an investigation.

9. Record review of discharged Patient #18's ED physician and Nurses' Note documentation dated 11/12/13 showed the following:
- Patient #18 presented to the ED at 11:33 PM with a left upper chest stab wound.
- At 12:54 AM, the ED Physician ordered soft restraints. The physician failed to include what limbs were to be restrained, and why the restraint was ordered.
- Staff failed to document any restraint assessments from initiation through discharge at 1:29 AM.

10. Record review of discharged Patient #19's ED physician and Nurses' Note documentation dated 10/12/13 showed the following:
- Patient #19 presented to the ED at 9:04 AM with an altered mental status related to alcohol intoxication. The patient had been in a fight.
- At 11:09 AM, the ED physician ordered a restraint for the patient. The physician failed to include what limbs were to be restrained, what type of restraint was to be used, and why the restraint was ordered.
- At 11:11 AM, the nurse documented the patient was combative and uncooperative, climbing out of bed and unsteady on his feet. The "patient was placed in restraints for safety, arms only."
- Staff failed to document any restraint assessments from initiation through discharge at 12:19 PM

11. Record review of the QA report for fiscal year 2013 and the QA plan for fiscal year 2014 showed no quality measures for restraint use in the ED.

12. During an interview on 01/09/14 at 8:21 AM, Staff Z, QA Coordinator, stated the following:
- If communication of hospital issues warranted inclusion into the QA program, they acted on it.
- It was the department Manager's responsibility to bring issues to the QA meetings to discuss.
- Restraints were not identified, or trended, in the ED per the QA program.
- Staff Z was unaware of the event involving Patient #20.

Based on observation, interview and policy review, the facility failed to ensure fresh water supply resources for one of one ice machine in the Acute Care clean utility room remained free of potential contamination from human waste or infectious waste; and failed to maintain easily cleanable surfaces of floors in the Central Sterile processing room and wheeled equipment in the operating rooms to preserve a sanitary environment. These failures have the potential to capture and spread infectious material between visitors, staff and patients. The facility census was 12.

Findings included:

1. Observation on 01/07/14 at 3:05 PM, showed no anti-siphon device (backflow preventer to keep contaminated water from being siphoned or sucked out of the basin and into the sanitary water supply) or air gap pipe in the drain line of a wall-mounted ice dispenser. The drain tube ran directly into a wall mounted pipe that led to a sewer line. In the unlikely event of a drain stoppage, or plugged sewer line, the backflow could create a cross connection between the fresh resource and contaminated untreated water from the facility sewer lines.

2. During an interview on 01/07/14 at 2:20 PM, Staff F, Assistant Maintenance Director, acknowledged the finding. He stated that checks for backflow and plumbing problems were not addressed by a specific policy or preventive maintenance checklist.

3. Review of the facility's policy titled, "Infection Control Policy for Surgery-Sanitation," Part D, dated 02/07/92 states; "Wheels and casters are cleaned and kept free of debris" and "Transportation and utility carts are cleaned daily with special attention given to the wheels and casters."

4. Observation on 01/08/14 at 2:10 PM, showed rusty casters on a single ring stand in Operating Room #2. In Operating Room #1, rusty casters were observed on a stainless steel table, ring stand, IV pole stand (for intravenous-drug, nutrient solution or other substance administered into a vein) and a two drawer stainless steel table.

5. Observation on 01/07/14 at 2:20 PM, showed a chipped floor tile below a wall-mounted fire extinguisher in the Central Sterile preparation area with a two inch square piece missing from the corner exposed a tacky black adhesive surface.

6. During interviews on 01/08/13 at 2:20 PM, Staff C, interim medical/surgical nursing director, stated that the casters are frequently exposed to water and harsh cleaning chemicals. She stated that there is currently no plan or procedure in place to schedule replacement wheels and no monitoring process to report when furniture or equipment becomes damaged or no longer cleanable.

Based on interview, record review and policy review the Chief Executive Officer (CEO/Administrator) failed to identify, direct and monitor the development and review, with necessary revisions, the facility's health care policies related to nursing, pharmacy, infection control, administration, privacy and the Emergency Department (ED) so that they were relevant and current for staff to utilize. This had the potential to affect patient care as policies in many departments were found to be outdated. The facility census was 12.

Findings included:

1. Even though requested, the facility failed to provide a written policy on how, when and by whom the facility's policies would be reviewed and/or revised.

2. Record review of the administrative policy titled, "Board of Directors, Chief Executive Officer (Administrator)," dated 03/25/91, showed direction for the CEO to advise and keep the governing board informed on the significant trends which will enable it to carry out policy formulation, including conditions within the facility which required action by the governing board. The policy also showed direction for the CEO to submit periodic reports including patient care services and the results of services rendered by facility policy.

3. Record review of policies showed the following outdated policies related to patient care:
- Four pharmacy policies had not been reviewed since 2002, two of which were effective in 1995 and 1997.
- Four nursing service policies had no current review dates and were effective in 2001, 2002, 2004 and 2008.
- Two infection control policies had no current review dates and were effective in 1991 and 1999.
- Twelve of 12 administrative policies that governed the provision of safe patient care were dated 06/88.
- Twenty-one of 21 HIPAA privacy (Health Insurance Portability and Accountability Act, that governed the protection of individuals' private health information) policies were dated 04/15/03.

4. Record review of the ED policy manual, on 01/08/14, showed approximately 75% of the patient care policies had not been reviewed/revised since 10/97, or 16 years.

5. During an interview on 01/10/14 at 8:53 AM, Staff L, Administrator, stated, "Our policies are outdated." He also stated that there was no committee responsible for the policy updates, that it was the director of each department's responsibility to do the updates. Staff L stated that he had not monitored the review of the facility policies and that he expected all policies to be reviewed on an annual basis and revised as necessary.










31891




32280

Based on observation, interview, record review, and policy review the facility failed to:
- Ensure the proper placement of clean linens in patient rooms for two patients (#9 and #10) of eight patients observed.
- Ensure nursing staff did not wear nail polish.
- Ensure hand hygiene and glove use were used when staff provided care to five patients (#1, #5, #9, #8, and #7) of eight patients observed.
These failed practices increased the risk of infection and cross contamination and placed all patients and personnel at risk for hospital acquired infections (HAI) and contracting communicable diseases. The facility census was 12.

Findings included:
1. Record review of the facility's policy titled, "Universal Precautions," reviewed 01/13, for Hand Hygiene showed the following:
- Hand hygiene measures are the single most important strategy for preventing nosocomial infections.
- Hand hygiene applies to hand washing, antiseptic hand rub or surgical hand antisepsis.
- Hand hygiene can be achieved with either soap or alcohol based hand sanitizer. Washing with soap suspends microorganisms and allows them to be mechanically removed by rinsing. Hand cleaning with anti-microbial products kills or inhibits the growth of microorganisms; this process is referred to as antisepsis.
- The skin of patients and personnel can function as a reservoir of infectious agents.
- All hospital personnel shall wash their hands to prevent the spread of infections during the following:
- When coming on duty;
- Between all patient contacts;
- Before performing invasive procedures;
- Before medication preparation;
- Before donning and after removing gloves;
- When moving from a contaminated body site to a clean body site;
- After contact with inanimate objects in the immediate vicinity of the patient such as medical equipment, furniture, linens, etc.

Record review of the facility policy titled, "Universal Precautions," reviewed 01/13, for Gloves showed the following:
- It is the policy of this facility that gloves be worn when handling blood or body fluids, mucous membranes and non-intact skin.
- When gloves are indicated they shall be used only once and discarded into the appropriate receptacle.
- Hand washing is necessary even if gloves are used. Gloves do not replace hand washing.
- Gloves should be worn if handling soiled linen or items that may be contaminated.
- During invasive procedures.

Record review of the facility policy titled, "Universal Precautions", reviewed 01/13, for Standard Precautions showed the following direction:
- To treat all body fluids from all patients as potentially infective. These precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.
- When performing vascular access procedures;
- When handling or touching contaminated items or surfaces;
- Gloves should be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.

Record review of the facility's undated policy titled, "Dress Code for Nursing Departments," showed facility staff were to keep fingernails clean and neat with tips no longer than 1/8", no artificial nails and no nail polish.

2. Observation on 01/07/14 at 8:53 AM showed Staff V, Certified Nurse Assistant (CNA) failed to place clean linens onto a clean surface when she entered Patient #9 and #10's room to change the bed linen. Staff V placed the clean linens on top of the closed lid of the bedside commode (a portable toilet placed beside a patient's bed for those who have difficulty walking to the bathroom).

3. During an interview on 01/07/14 at 8:56 AM, Staff V, CNA stated that she usually placed clean linens in the patient recliners but she was unable to do this today as both patients were seated in them. She stated that she was instructed not to place linens in the window sill and the bedside tables were full so sometimes the bedside commodes were the only place available.

4. Observation on 01/07/14 at 8:58 AM showed Staff P, Registered Nurse (RN) failed to perform hand hygiene in between glove changes and between tasks on the same patient and failed to follow facility policy of no nail polish when she administered medications to Patient #9. Staff P was observed to have chipped nail polish on all ten fingernails. Staff P put on gloves and scanned the patient's identifying bracelet. Wearing the same gloves Staff P typed on the computer, applied a Nitroglycerin Transdermal Patch (a medication patch applied to the skin to prevent episodes of chest pain in patients who may have narrowing of the blood vessels that supply blood to the heart), then removed her right glove, put on a clean glove and administered an intravenous (within the vein) flush.

5. During an interview on 01/07/14 at 9:08 AM Staff P stated that she had removed her right hand glove and put on a clean one before she flushed the IV and thought that was good enough. She stated that she didn't realize she should have performed hand hygiene between glove changes, administering medications and charting on the computer. Staff P stated she was unaware of any facility policy related to nail polish.

6. Observation on 01/07/14 at 3:05 PM showed Staff B, RN, failed to perform hand hygiene when entering an Emergency Department (ED) bay to start an IV on Patient #1. Staff B put gloves on, attempted to start the IV but was unsuccessful, so she left the ED bay with her gloves on to retrieve some scissors from the ED department. She returned to the ED bay with the same gloves on and attempted a second time to start an IV. This attempt was also unsuccessful so she took her gloves off and went to the nurses' station to answer the phone. Staff B came back into the patient's ED bay, without washing or sanitizing hands, and put gloves on to start a urinary catheter (a tubing placed into the bladder to remove urine-this procedure can introduce bacteria into the bladder causing an infection). (Staff B failed to wash or sanitize her hands when she removed the regular gloves to put sterile gloves on, which were in the catheter kit). The patient was ultimately admitted to the hospital with urosepis (an infection in the urinary bladder).
7. Observation on 01/08/14 at 9:28 AM showed Staff D, Physical Therapist, failed to change gloves, wash and sanitize her hands, and put clean gloves on when she went from the dirty portion of a dressing change to the cleaner portion of a dressing change on Patient #5.

8. Observation on 01/08/14 at 9:45 AM showed Staff M, RN, failed to perform hand hygiene when entering patient room 116 to provide care to two patients (#8 and #7). She set up the medications for Patient #8 and administered nasal spray while holding the oxygen tubing attached to the patient's nostrils. She then administered an IV flush without performing hand hygiene and applying gloves. She then proceeded to set up medications for Patient #7. She administered an IV flush and injected insulin subcutaneous (beneath the skin) without performing hand hygiene and applying gloves.

9. During an interview on 01/08/14 at 10:10 AM, Staff M, RN, stated that she knew she should perform hand hygiene between patient care and patient contact. She stated she just missed it (performing hand hygiene) and she was unaware if she had to wear gloves when administering an IV flush or when injecting insulin.

10. During an interview on 01/08/14 at 10:20 AM, Staff C, RN supervisor, stated that hand hygiene was required when entering and leaving a patient's room. Hand hygiene and application of gloves was required before an IV flush and an insulin injection.

11. During an interview on 01/08/14 at 2:30 PM, Staff N, RN, Director Infection Control, stated that she was unaware that staff had been instructed not to place clean linens on the window sill in patient rooms. She stated she did not agree with clean linens being placed on bedside commodes and would expect clean linens to be placed on a freshly cleaned bedside table. She stated that in accordance to the dress code policy chipped nail polish was not allowed. Staff N stated that she expected staff to change gloves from the dirty portion of a dressing change to the clean portion of the dressing change. Staff N also stated that staff should not leave a patient's room with gloves on and re-enter the room without sanitizing or re-gloving. She also stated that Staff M should have performed hand hygiene before patient care including nasal spray, IV flushes, and medication administration.







31891











12450

Based on observation and interview, facility dietary staff failed to clean and maintain kitchen food preparation and storage equipment in accordance with the US Food and Drug Administration (FDA) 2013 food code in order to manage and preserve a sanitary environment, free from surface and overhead contamination for cooking, preparation and service of food products. This deficient practice and failure to follow nationally recognized FDA standards of environmental sanitation for food storage and preparation areas has the potential for the spread of food borne illness to all visitors, staff and patients. The facility census was 12.

Findings included:

1. Record review of the US Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2013 Food Code directed the following:
- Chapter 4-601.11(B) The food-contact surfaces of cooking equipment and pans shall be kept free of an accumulation of dust, dirt, food residue and other debris.
- Chapter 4-601.11(C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt food residue and other debris.
- Chapter 4-602.13 Nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
- Chapter 6.201.11 Floors, floor coverings, walls, wall coverings and ceilings shall be designed constructed and installed so they are smooth and easily cleanable.
- Chapter 3-305.11, Food Storage.
- Chapter 3-501.16, Time/ Temperature Control for Safety Food, Hot and Cold Holding.

2. Observation on 01/08/14 at 3:00 PM in the facility kitchen showed staff failed to clean and maintain the following:
- Missing portion of a ceiling tile above the steam table measured 24 inches deep by five inches wide and exposed the unfinished area above the kitchen ceiling.
- Rusty shelf units used for storage of food products-six floor-to-ceiling units in the food pantry and three more similar shelf units in another room used for paper and plastic storage. The green painted surface on all the shelves was chipped and scraped, and exposed brown-colored corroded steel surfaces.
- Thick deposits of dust on the rails of can racks.
- Food debris, grease deposits and brownish grease film coated the inside cabinet and floor of a deep fryer on the cook line.
- Peeling surface and edges on the Formica covered serving shelf of the steam table
- Thermometer missing and no temperature log for a two door refrigerator located behind the steam table and service line.

3. During an interview on 01/08/14 at 3:30 PM, Staff AA, Director of Dietary Services acknowledged the observations and stated he was not sure what had happened to the ceiling tile. He stated that maintenance had been in recently and was working up there. He stated that the facility currently had plans to replace the shelves with wire shelves; however, no timeline or installation date had been established. He stated that cleaning the can racks and deep fryer cabinet was infrequent and not addressed in any specific kitchen cleaning policies.

Based on interview, record review and policy review the facility failed to ensure that facility policies were updated and reviewed annually. There were numerous outdated policies for administration; infection control; the emergency department (ED), quality assurance (QA); nursing; pharmacy and surgical services. These failed processes increased the risk of improper care and placed all patients at risk for receiving inadequate care throughout the facility. The facility census was 12.

Findings included:

1. Record review of policies showed the following outdated policies related to patient care:
- Four pharmacy policies had not been reviewed since 2002, two of which were effective in 1995 and 1997.
- Four nursing service policies had no current review dates and were effective in 2001, 2002, 2004 and 2008.
- Two infection control policies had no current review dates and were effective in 1991 and 1999.
- Twelve of 12 administrative policies that governed the provision of safe patient care were dated 06/88.
- Twenty-one of 21 HIPAA privacy (Health Insurance Portability and Accountability Act, that governed the protection of individuals' private health information) policies were dated 04/15/03.

2. Record review of the ED policy manual, on 01/08/14, showed approximately 75% of the patient care policies had not been reviewed/revised since 10/97, or 16 years.

3. During an interview on 01/07/14 at 2:50 PM, Staff A, ED Manager, stated that she was in the process of reviewing the policies.

4. During an interview on 01/09/14 at 2:15 PM, Staff Y, Registered Nurse (RN), stated that she had worked at the facility for over 10 years and the policies were very outdated.

5. During an interview and concurrent QA record review on 01/10/14 at 8:30 AM, Staff Z, QA supervisor stated that the QA policies had not been revised since 1991 and that she had not been involved in revising policies.

6. During an interview on 01/10/14 at 8:53 AM, Staff L, Administrator, stated, "Our policies are outdated." He also stated that there was no committee responsible for the policy updates that it was the directors of each department's responsibility to do the updates. Staff L stated that he had not monitored the review of facility policies and that he expected all policies to be reviewed on an annual basis and revised as necessary.





31891









12450

Based on observation, interview, record review, and policy review the facility failed to validate the dosage of a high risk medication (Insulin, a medication used to regulate the amount of glucose/sugar in the blood) with a second nurse for one patient (#7) of one current patient observed before medication was administered. The facility also failed to follow their policy for administration of a Heparin (blood thinner) flush in an intravenous (IV, in the vein) line for one patient (#5) of one patient observed with a Heparin IV flush. The facility also failed to administer a nasal spray (Oxymethazoline) per orders and policy to one patient (#6) of one patient observed with nasal spray orders. These failures had the potential to place all patients at risk of a harmful medication reaction. The facility census was 12.

Findings included:

1. Record review of the facility's policy titled, "Medication Administration" dated 10/30/13, showed that two nurses must check the medication dosage ordered and the amount prepared for accuracy before insulin was administered.

2. Observation and concurrent interview on 01/08/14 at 9:55 AM showed Staff M, Registered Nurse, failed to validate the order for insulin and dosage prepared for injection with a second nurse before she administered the medication to Patient #7. Staff M stated that the facility did not require validation of insulin dosage by a second nurse.

3. During an interview on 01/10/14 at 9:05 AM, Staff J, Director of Nursing, stated that insulin required validation by two nurses before administration.

4. Record review of the facility's policy titled, "Care of PICC Lines (peripherally inserted central catheter-a type of IV), dated 02/12/04, showed direction to flush the IV line with three cubic centimeters (cc's) normal saline followed by two cc's Heparin every 12 to 24 hours.

5. Record review of Patient #5's Physician's Orders for a PICC, dated 12/26/13, showed staff were to flush the catheter daily with two cc's Heparin.

6. During observation and concurrent interview on 01/08/14 at 8:55 AM, Staff M, RN stated that the facility policy directed staff to administer three cc's of Heparin from a pre-filled syringe as a flush to the PICC line. Staff M flushed Patient #5's PICC line with three cc's of Heparin, rather than two cc's per the order/policy.

7. Record review of the facility's policy titled, "Self Administration of Medication," reviewed 03/02, showed direction that patients were allowed to self-administer medications only upon the order of the physician.

8. Observation on 01/08/14 at 8:43 AM, showed Staff M handed Patient #6 her nasal spray to self-administer. The patient administered two sprays in each nostril.

9. Record review of Patient #6's physician's orders showed no order to self-administer the nasal spray, and the order was for only one spray in each nostril, not two. (Staff failed to follow their policy and the physician's orders for the nasal spray).





12450

Based on interview, record review and policy review the facility failed to individualize care plans to ensure potential care needs and response to interventions are addressed for two (#10, #4) of eight patients reviewed. This failure had the potential to deny all patients admitted to the facility care plan interventions needed to meet their needs. The facility census was 12.

Findings included:

1. Record review of the facility's policy titled, "Rules and Regulations" dated 10/23/08 showed the following:
- Each patient admitted to the Acute Care Unit shall receive a complete head-to-toe assessment by a qualified individual so that a Plan of Care can be developed to best meet the needs of the patient. The assessment of the care or treatment needs of the patient will be ongoing throughout the patient's hospital stay.
- At the time of admission, each patient shall have an initial physical/psychological assessment completed by a Registered Nurse or a Licensed Practical Nurse under the direct supervision of a Registered Nurse.
- Upon completion of the initial admission assessment, an individualized prioritized Plan of Care will be developed.
- The plan of care will be reviewed regularly and revised as the patient's condition or diagnosis changes.

2. Record review of Patient #10's History and Physical (H&P) on 01/08/14 at 10:30 AM showed the patient was admitted to the facility on 12/30/13 for Urosepsis (a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream) and pneumonia. Further record review showed the patient had a diagnosis of seizure disorder and takes Levetiracetam (a medication specifically used to treat partial onset seizures in people with epilepsy) twice daily.

3. Record review of Patient #10's medical record showed no individualized plan of care in relation to seizure disorder. The existing nursing care plans showed an initiation date of 12/30/13.

4. During an interview on 01/08/14 at 12:45 PM Staff P, Registered Nurse, (RN) stated that there were no interventions specific to Patient #10's seizure disorder and that there should have been.

5. Record review of Patient #4's H&P dated 01/03/14, showed the patient was admitted to the facility on 01/02/14 for severe diarrhea, vomiting, and nausea, secondary to Influenza, type A (a type of flu that was contagious to others).

6. Record review of Patient #4's physician order dated 01/03/14 and timed at 8:17 AM, showed the physician ordered isolation (procedures to prevent the spread of infection) for the positive Influenza A test results.

Record review of Patient #4's physician order dated 01/06/14 and timed at 2:40 PM, showed the physician discontinued isolation.

7. Record review of Patient #4's nursing care plan dated 01/02/14, showed no care plan for isolation from 01/03/14 to 01/06/14.

8. During an interview on 01/08/14 at 10:20 AM, Staff C, RN supervisor, stated that a nurse should have updated the treatment plan to include isolation.



31891

Based on interview, record review, and policy review, the facility failed to monitor and document three (#20, #18, and #19) of three discharged Emergency Department (ED) patients' pertinent information and response to the use of restraints (devices used to immobilize a patient's arms, legs, body or head for their safety). This failure could cause misuse of restraints and the potiential for harm for all patients in the ED. The average number of visits in the ED were 182 weekly. The facility also failed to have diagnostic reports promptly available for physician assessment and treatment in one (#7) of eleven current patients reviewed who had radiology testing performed. This failure could result in a delay of treatment and had the potential to affect all patients. The facility census was 12.

Findings included:

1. Record review of the facility's policy titled, "Restraints," revised 06/01/08, showed the following:
- Patients have the right to be free from the use of restraints, of any form, as a means of convenience or coercion.
- Restraints used to manage behaviors is an emergency measure and increased vigilance is required because of the heightened potential for harm or injury as the patient struggles or resists.
- There is immediate need for assessment of what has triggered a behavior and for continuous monitoring of the patient's condition.
- Documentation should include least restrictive measures considered, the patient's response to the intervention, and the patient should be reassessed every 30 minutes for signs of injury, nutrition, hydration, circulation and elimination.

2. Record review of discharged Patient #20's ED physician and Nurses' Note documentation, dated 12/08/13, showed the following:
- Patient #20 presented to the ED at 2:27 AM with complaints of suicidal ideations.
- At 6:14 AM, the ED physician wrote an order to restrain the patient related to unsafe behaviors. (Facility staff failed to document a restraint assessment and/or document lesser restrictive measures attempted prior to the restraint application per their policy. Staff also failed to document what type of restraints were used and what limbs were restrained).
- At 7:02 AM, the patient pulled his right arm out of restraints and sat up in bed. (Staff failed to re-assess the type and reason for the restraint and/or document the 30-minute restraint assessment at 6:44 AM. Staff also failed to document the 30-minute restraint assessment at 7:32 AM, and at 8:02 AM).
- At 8:38 AM, the patient was seen crawling around on the ED floor trying to leave the ED without being seen. The patient was placed back in four-point restraints (both wrists and both ankles). (Staff failed to re-assess the type and reason for the restraints. Staff also failed to document the 30-minute restraint assessments from 10:00 AM through 6:54 PM.

3. Record review of discharged Patient #18's ED physician and Nurses' Note documentation dated 11/12/13 showed Patient #18 presented to the ED at 11:33 PM with a left upper chest stab wound. At 12:54 AM, the ED physician ordered soft restraints. The physician failed to include what limbs were to be restrained, and why the restraint was ordered. (Staff failed to document any restraint assessments from initiation through transfer to another hospital at 1:29 AM).

4. Record review of discharged Patient #19's ED physician and Nurses' Note documentation dated 10/12/13 showed Patient #19 presented to the ED at 9:04 AM with an altered mental status related to alcohol intoxication. The patient had been in a fight. At 11:09 AM, the ED physician ordered staff to restrain the patient. (The physician failed to include what limbs were to be restrained, what type of restraint was to be used, and why the restraint was ordered. Staff also failed to document any restraint assessments from initiation at 11:09 AM through discharge at 12:19 PM).

5. Record review of the facility's undated policy titled, "Medical Records, General Statement and Purposes," showed that:
- A medical record was maintained for each individual who is evaluated or treated.
- Each record contained accurate documentation that was documented in an expeditious manner.
- The record was readily accessible to permit prompt retrieval of information.
- The record served as a basis for planning patient care, for continuity of care, and for evaluation of the patient's condition.

Record review of the facility's undated policy titled, "Professional Practice Review Process," showed that the facility's objective was to establish, maintain, support, and document patient care evaluations and appropriate responses to problems identified

6. Record review of Patient #7's H & P dated 01/03/14, showed the patient was admitted on the same date with shortness of breath.

7. Record review of Patient #7's radiology report dated 01/05/14, showed a chest x-ray was ordered for shortness of breath and was conducted by radiology staff on 01/03/14. The radiologist read the x-ray films and dictated the results of the x-ray on 01/05/14, approximately two days after the test was completed.

8. During an interview on 01/07/14 at 3:45 PM, Staff E, Licensed Practical Nurse, stated that x-ray results and reports from the radiologist were usually late.

9. During an interview on 01/08/14 at approximately 1:30 PM, Staff I, physician, stated that delayed radiology reports was a continued problem without resolution, and that could cause delayed treatment and an increased length of stay.

10. During an interview on 01/09/14 at 10:50 AM, Staff R, Radiology Director, stated that routine x-rays should be read by the physician within 12 to 24 hours after the test was performed. She was unaware of the problem of delayed dictation of the report by the physician. She also stated she was not responsible for and did not conduct quality monitoring for physician radiology report completion.








12450

Based on observation, interview, and policy review, the facility failed to provide safeguards to prevent unauthorized access of medical records. These failed practices increased the risk of unauthorized access and placed current and discharged patients at risk for a breach of patient confidentiality. The facility census was 12.

Findings included:

1. Record review of the facility's policy titled, "HIPAA Privacy, Minimum necessary requirement" (Health Insurance Portability and Accountability Act, that governs the protection of individuals' private health information) dated 04/15/03, showed that environmental services staff, including maintenance and housekeeping were not permitted access to confidential healthcare information.

2. Observation on 01/10/14 at 9:05 AM, Staff O, Medical Records supervisor, showed:
- One entrance to the medical records department with numerous unlockable and open shelving units, which contained medical records. Observation also showed medical records sitting on desks and tables plus boxes with medical record information.
- During a concurrent interview Staff O stated that the medical records department was open from 8:00 AM to 4:30 PM during the week, and closed on weekends.
- The medical records department had current patient medical record information and stored medical records of discharged patients.
- Medical records, administrative, maintenance and housekeeping staff had keys to the medical records department where the patient records and information were stored.
- Housekeeping staff cleaned the department after hours.
- The need for additional security of records in the department had previously been discussed.




04467

Based on interview and policy review the facility failed to have an effective Emergency Department (ED) quality assessment (QA) program because they failed to identify, track, and/or monitor the use of restraints (devices used to immobilize a patient's arms, legs, body or head for their safety), and any adverse outcome from their use, for three (#20, #18, and #19) of three restrained, discharged ED patients, in the prior three months. This could cause injuries, or other problems related to restraint usage to go unnoticed and uncorrected for all patients restrained in the ED. The average ED visits were 182 per week. The facility census was 12.

Findings included:

1. Record review of the facility's ED policy titled,"Quality Control Mechanisms," revised 10/07, showed no inclusion of restraints in the ED QA plan/program.

2. Record review of the facility's undated Professional Practice Review Process (from the overall QA Plan), showed the following:
- The objective of the QA program was to establish, maintain, support and document evidence of ongoing mechanisms for objective patient care evaluation and for appropriate responses to problems identified.
- The appropriateness and quality care shall be demonstrated by compliance to standards of practice, policies and that services were provided at the right time and right level of care.
- On-going collection, and evaluation, of information about important aspects of patient care to identify opportunities for improvement, and to identify problems and impact on patients.
- Improvement of the quality of patient care and resolution of identified problems through actions taken as appropriate.
- The QA plan shall be flexible to allow for prompt intervention for those identified problems quality of patient care.

3. Record review of discharged Patient #20's ED physician and Nurses' Note documentation, dated 12/08/13, showed the following:
- Patient #20 presented to the ED at 2:27 AM with complaints of suicidal (thoughts of self-harm) ideations. The patient had already carved (with a razor blade) his sister's name, and branded it (with a heated clothes hanger), into his left forearm. The patient had also taken an overdose of sleeping and anti-seizure medications.
- At 6:14 AM, the ED physician wrote an order to restrain the patient related to behaviors and an actual elopement (an unsafe patient leaving the hospital without staff permission) from the facility.
- At 8:50 AM, the patient was secured with a C-Collar (a head/neck immobilization device) and tape (around the patient's forehead and attached to the underside of the mattress) because the patient continued to struggle against the wrist/ankle restraints and tried to elope again.
- At 1:05 PM, the patient got out of restraints again and walked toward the ED door (attempting to elope again).
- At 1:15 PM, the restraints were inspected by staff and noted they had been cut. The patient admitted he had found trauma sheers (scissors) in the ED bay and he hid them under the ED mattress. (The patient could have used these scissors to cut himself, [since he was a suicidal or high risk patient], or others).
- Patient #20 remained in restraints, during most of his stay in the ED, from 6:14 AM through 6:54 PM.

4. Record review of discharged Patient #18's ED physician and Nurses' Note documentation dated 11/12/13 showed the following:
- Patient #18 presented to the ED at 11:33 PM with a left upper chest stab wound.
- At 12:54 AM, the ED physician ordered soft restraints.
- The patient remained in restraints from initiation through discharge at 1:29 AM.

5. Record review of discharged Patient #19's ED Physician and Nurses' Note documentation dated 10/12/13 showed the following:
- Patient #19 presented to the ED at 9:04 AM with an altered mental status related to alcohol intoxication. The patient had been in a fight.
- At 11:09 AM, the ED Physician ordered a restraint for the patient.
- At 11:11 AM, the nurse documented the patient was combative and uncooperative, climbing out of bed and unsteady on his feet.
- The patient remained in restraints from initiation through discharge at 12:19 PM.

6. During an interview on 01/09/14 at 9:05 AM, Staff A, Registered Nurse (RN) ED Manager, stated that she did not know how many patients had been restrained in the ED in the prior three months, but did know of at least one patient in the prior two months as the restraints were destroyed (cut). Staff A stated that the ED had not identified and/or tracked the use of restraints in their departmental QA.

7. Record review of the QA report for fiscal year 2013 and the Quality assurance plan for fiscal year 2014 showed no quality measures for restraint use in the ED.

8. During an interview on 01/09/14 at 8:21 AM, Staff Z, QA Coordinator, stated the following:
- If communication of hospital issues warranted inclusion into the QA program, they acted on it.
- It was the department Manager's responsibility to bring issues to the QA meetings to discuss.
- Restraints were not identified, or trended, in the ED per the QA program.
- Staff Z was unaware of the event involving Patient #20.

Based on observation, interview, record review and policy review, the facility failed to communicate available activities via a calendar, and failed to identify and/or provide activities of specific interest for four (#3, #5, #6, and #12) of four Swing Bed patients (a specific type of reimbursement for patients that need a skilled service [such as therapy], but don't need the level of care in a regular patient bed) patients reviewed. This had the potential to deny all Swing Bed patients admitted to the facility their actual interests in activities. The current Swing Bed census was four and the facility census was 12.

Findings included:

1. Record review of the facility's Swing Bed policy titled, "Patient Activities," reviewed 04/13, directed that the Activity Director (AD) make certain the activities are designed to promote physical, social and mental well-being of the patients. The AD will provide activities designed to promote opportunities for the patient to engage in normal pursuits, including religious activities. Activities will satisfy the individual interests of the patients.

2. Record review of the facility's Swing Bed Job Description for the AD, reviewed 04/13, showed the AD was responsible for the following:
- Assess the patient's needs and interests.
- Develop and implement individual and/or small group activities to achieve identified goals.
- Facilitate the patients' participation in activities to meet the needs of each patient.
- Communicate each patient's program to families and staff, through the posting of a large monthly calendar in a centralized location.

3. Record review of Patient #3's History and Physical (H & P) dated 01/03/14, showed the patient was admitted to the Swing Bed program on 01/02/14 with diagnoses of post left hip repair and need for therapy.

4. Observation and concurrent interview on 01/08/14 at 11:00 AM, showed no activity calendar available/posted for Patient #3. Patient #3 stated that he was unaware of any activity program, and had not been offered any activities during his stay. The patient stated that he enjoyed computers, sports programs, reading the newspaper, walking outside when the weather permitted, cooking breakfast, and spending time with his girlfriend and grandchildren.

5. Record review of Patient #3's Activity Assessment dated 01/06/14, timed 4:06 PM, showed the patient walked with a cane, and was completely alert and oriented. The patient enjoyed watching television (TV), movies, and listening to the radio. (Staff failed to document any specific TV programs, movies, or type of music, and failed to identify other areas of interest.)

6. Record review of the patient's activity participation documentation showed only one entry dated 01/08/14. "Lots of company today, looks better today, more energy, no needs or concerns." (Staff failed to document any specific, relevant activities provided for Patient #3).

7. Record review of Patient #5's H & P dated 12/31/13, showed the patient was admitted to the Swing Bed program on 12/22/13 with a diagnosis of a left leg wound requiring specialized treatment.

8. Observation and concurrent interview on 01/08/14 at 8:51 AM, showed no activity calendar available/posted for Patient #5. Patient #5 stated that she was unaware of any activity program. The patient stated that she enjoyed TV and puzzles at times.

9. Record review of Patient #5's Activity Assessment dated 01/03/14, timed 1:02 PM, showed the patient was unable to walk, and was completely alert and oriented. The patient preferred activities in her room and enjoyed watching television (TV), movies, and listening to the radio. (Staff failed to document any specific TV programs, movies, or type of music, and failed to identify other areas of interest.)

10. Record review of the patient's activity participation documentation showed only one entry dated 01/08/14. "Husband with her visiting most of the day." (Staff failed to document any specific, relevant activities provided for Patient #5).

11. Record review of Patient #6's H & P dated 12/26/13, showed the patient was admitted to the Swing Bed program on 12/25/13 with a diagnosis of a post left thigh bone fracture with repair requiring therapy.

12. Observation and concurrent interview on 01/08/14 at 10:50 AM, showed no activity calendar available/posted for Patient #6. Patient #6 stated that she enjoyed reading, playing cards occasionally, gardening and music.

13. Record review of Patient #6's Activity Assessment dated 01/03/14, timed 1:02 PM, showed the patient walked with a cane or walker, and was completely alert and oriented. The patient preferred activities in her room and enjoyed watching television (TV), movies, and listening to the radio. (Staff failed to document any specific TV programs, movies, or type of music, and failed to identify other areas of interest.)

14. Record review of the patient's activity participation documentation showed only one entry dated 01/08/14. "No needs or concerns, tired today, watching some TV, some visitors." (Staff failed to document any specific, relevant activities provided for Patient #6).

15. Record review of Patient #12's H & P dated 12/24/13, showed the patient was admitted to the Swing Bed program on 12/11/13 with a diagnosis of pneumonia requiring therapy for strengthening.

16. Record review of Patient #12's Activity Assessment dated 12/24/13, timed 2:41 PM, showed the patient walked with assistance, and was completely alert and oriented. The patient preferred activities in her room and enjoyed music, reading, writing, TV, movies, and listening to the radio. (Staff failed to document any specific TV programs, movies, reading material, or type of music, and failed to identify other areas of interest.)

17. Record review of the patient's activity participation documentation showed only one entry dated 01/08/14. "Very tired today, sleepy." (Staff failed to document any specific, relevant activities provided for Patient #12).

18. During an interview on 01/08/14 at 2:00 PM, Staff W, AD, stated the following:
- She was employed full-time as the AD for the facility's long-term care facility and spent approximately five to thirty minutes, three times weekly, per patient, on the Swing Bed unit.
- She confirmed there was no activity calendar for the Swing Bed patients.
- She confirmed she needed to individualize the activity program to the patient's assessed needs/abilities, and document participation and/or encouragement to attend.

Based on observation, interview, record review and policy review, the facility failed to develop a comprehensive, individualized activity care plan for four (#3, #5, #6, and #12) of four Swing Bed patients (a specific type of reimbursement for patients that need a skilled service [such as therapy], but did not need the level of care in a regular patient bed) patients reviewed. This had the potential to deny all Swing Bed patients admitted to the facility the individualized activities they need. The current Swing Bed census was four and the facility census was 12.

Findings included:

1. Record review of the facility's Swing Bed policy titled, "Patient Activities," reviewed 04/13, directed that the Activity Director (AD) make certain the activities are designed to promote physical, social and mental well-being of the patients. The AD will provide activities designed to promote opportunities for the patient to engage in normal pursuits, including religious activities. Activities will satisfy the individual interests of the patients.

Record review of the facility's Swing Bed policy titled, "Care Plans," reviewed 04/13, showed activities interventions possible based on problems of the patient, such as crafts/games for the patient that had decreased muscle or mobility.

2. Record review of the facility's Swing Bed Job Description for the AD, reviewed 04/13, showed direction for the AD to plan, coordinate and direct the patient's activity program based on the individualized needs as identified in each patient's care plan. The AD will record each patient's care plan for activities and subsequent reassessments. The AD will document the response the care plan.

3. Record review of Patient #3's History and Physical (H & P) dated 01/03/14, showed the patient was admitted to the Swing Bed program on 01/02/14 with diagnoses of post left hip repair and need for therapy.

4. During an interview on 01/08/14 at 11:00 AM, Patient #3 stated that he enjoyed computers, sports programs, reading the newspaper, walking outside when the weather permitted, cooking breakfast, and spending time with his girlfriend and grandchildren.

5. Record review of Patient #3's Activity Assessment dated 01/06/14, at 4:06 PM, showed the patient walked with a cane, and was completely alert and oriented. The patient enjoyed watching television (TV), movies, and listening to the radio. (Staff failed to document any specific TV programs, movies, or type of music, and failed to identify other areas of interest.)

6. Record review of the patient's activity care plan dated 01/06/14, showed the patient was at risk for decreased activity level so would be offered TV, visits with family, and social visits by AD several times weekly. (The AD failed to identify individualized interests and obtain specificity of assessed interests and tailor the care plan to the patient.)

7. Record review of Patient #5's H & P dated 12/31/13, showed the patient was admitted to the Swing Bed program on 12/22/13 with a diagnosis of a left leg wound requiring specialized treatment.

8. During an interview on 01/08/14 at 8:51 AM, Patient #5 stated that she enjoyed TV and puzzles at times.

9. Observations of Patient #5 on 01/08/14 at 8:51 AM and 10:45 AM, showed the patient lying in bed with no TV, music or other stimulating activity.

10. Record review of Patient #5's Activity Assessment dated 01/03/14, timed 1:02 PM, showed the patient was unable to walk, and was completely alert and oriented. The patient preferred activities in her room and enjoyed watching television (TV), movies, and listening to the radio. (Staff failed to document any specific TV programs, movies, or type of music, and failed to identify other areas of interest.)

11. Record review of the patient's activity care plan dated 01/03/14, showed the patient was at risk for decreased activity level so would be offered TV, visits with family, and social visits by AD several times weekly. (This care plan was identical to the care plan for Patient #3). The AD failed to identify individualized interests and obtain specificity of assessed interests and tailor the care plan to the patient.)

12. Record review of Patient #6's H & P dated 12/26/13, showed the patient was admitted to the Swing Bed program on 12/25/13 with a diagnosis of a post left thigh bone fracture with repair requiring therapy.

13. During an interview on 01/08/14 at 10:50 AM, Patient #6 stated that she enjoyed reading, playing cards occasionally, gardening and music.

14. Record review of Patient #6's Activity Assessment dated 01/03/14, timed 1:02 PM, showed the patient walked with a cane or walker, and was completely alert and oriented. The patient preferred activities in her room and enjoyed watching television (TV), movies, and listening to the radio. (Staff failed to document any specific TV programs, movies, or type of music, and failed to identify other areas of interest.)

15. Record review of the patient's activity care plan dated 12/26/13 showed the patient was at risk for decreased activity level so would be offered TV, visits with family, social visits by AD several times weekly, and has cell phone and talks to family daily. (This care plan was identical to the care plan for Patients #3 and #5 with the exception of the cell phone intervention. The AD also failed to identify individualized interests and obtain specificity of assessed interests and tailor the care plan to the patient).

16. Record review of Patient #12's H & P dated 12/24/13, showed the patient was admitted to the Swing Bed program on 12/11/13 with a diagnosis of pneumonia requiring therapy for strengthening.

17. Record review of Patient #12's Activity Assessment dated 12/24/13, timed 2:41 PM, showed the patient walked with assistance, and was completely alert and oriented. The patient preferred activities in her room and enjoyed music, reading, writing, TV, movies, and listening to the radio. (Staff failed to document any specific TV programs, movies, reading material, or type of music, and failed to identify other areas of interest.)

18. Record review of the patient's activity care plan dated 12/24/13 showed the patient was at risk for decreased activity level so would be offered TV, visits with family, social visits by AD several times weekly, and newspaper. (This care plan was identical to the care plan for Patients #3, #5, and #6 with the exception of the newspaper intervention). The AD failed to identify individualized interests and obtain specificity of assessed interests and tailor the care plan to the patient).

19. During an interview on 01/08/14 at 2:00 PM, Staff W, AD, confirmed it was her responsibility to develop and/or update the patient's activity care plan, per ongoing assessment and weekly multidisciplinary meetings.