HospitalInspections.org

Based on observation and interview, the facility failed to ensure proper ventilation monitoring was available when airborne isolation patients were present in the emergency department.
1. During a facility tour in the emergency department on 10-11-11 at 1425 hours, it was observed that the negative airflow patient isolation room 1136 lacked a visual monitoring system outside the room to continuously monitor the direction of airflow per the American Institute of Architects (2001) Hospital requirements 7.2.C7 "Rooms shall have a permanently installed visual mechanism to constantly monitor the pressure status of the room when occupied by patients with an airborne infectious disease. The mechanism shall continuously monitor the direction of the airflow."
2. During an interview on 10-11-11 at 1425, staff #A3 confirmed that no ventilation monitors for negative airflow isolation rooms had been installed in the emergency department or on the inpatient unit and tissue paper testing was performed to verify room airflow direction before an isolation patient was admitted to the room.

Based on record review, observation and interview, the facility failed to ensure 4 of 4 third shift fire drills were held at varying times over the past year to protect 22 of 22 patients and failed to ensure 7 of 52 smoke detectors were not located where airflow could prevent the operation of the detector.

Findings:

1. Based on review of the Monthly Fire Drill Reports with #DE on 10/13/11 at 7:40 a.m., the Monthly Fire Drill Reports for third shift were held at the following similar times: 02/25/11 at 12:00 a.m., 05/31/11 at 11:00 p.m., 08/30/11 at 11:45 p.m., and 12/31/10 at 12:50 a.m.
2. Based on interview with #DE on 10/13/11 at 8:00 a.m., the third shift starts at 11:00 p.m. and ends at 7:00 a.m. The similar times for the fire drills held on third shift were acknowledged by #DE during the record review at 7:40 a.m. on 10/13/11.
3. Observations on 10/13/11 during a tour of the facility from 7:50 a.m. to 11:50 a.m. with #DE indicated the Service Hall smoke detector near the communication room, the Medical Surgery Hall smoke detector by room 1019, the Medical Surgery Hall smoke detector by the soiled linen room, the Kitchen Hall smoke detector by the gift shop, the Central Hall smoke detector by the laboratory, the Central Hall smoke detector by the smoke barrier doors and the Central Hall smoke detector by the ultrasound room were each located from one foot to two feet from supply air ducts.
4. Observations were verified by #DE at the time of observations.

Based on patient medical record review and interview, the governing board and activity director failed to develop a policy related to the purpose and completion of the form: "Activity Evaluation and Plan of Treatment", and physician approval and authentication of the activity plan, for 4 of 4 current swing bed patients. (pts N5, N6, N7 and N14)

Findings:
1. review of open and closed swing bed patient medical records during the survey process of 10/11/11 to 10/13/11 indicated:
a. patients N5, N6, N7 and N14 had the form titled "Activity Evaluation and Plan of Treatment" in their medical records, but all were lacking authentication in the "Doctor's Signature" area of the form

2. interview with staff member NG at 9:35 AM on 10/12/11 indicated:
a. there is no policy and procedure, or written protocol, that addresses the process for completing the "Activity Evaluation and Plan of Treatment" form and when the physician needs to authenticate the treatment plan for activities therapy
b. it cannot be determined that the practitioner had been informed of the evaluation, and treatment plan that was developed, for pts. N5, N6, N7 and N14, without an authentication by the provider

Based on patient medical record review, policy and procedure review and staff interview, the facility failed to follow its "Fall Potential Assessment" policy for 1 of 3 current swing bed patients ((N6) and for 1 of 2 current medical surgical patients (N9), failed to follow its "Documentation-Pediatric" policy for 1 of 3 pediatric patients (N20), failed to follow its "Blood Glucose by Accuchek Advantage Meter" policy for 2 of 4 facility areas toured (obstetrics and surgery) and failed to follow its "Telephone and Verbal Orders" policy for 2 of 4 open swing bed patient records (N6 and N14), 1 of 1 obstetric records (N18) and for 2 of 3 closed pediatric patient records (N19 and N21).

Findings:
1. at 11:00 AM on 10/12/11, review of the policy and procedure "Fall Potential Assessment", PolicyStat ID: 74350 indicated under "Implementation", "1. Assessment will be done on every patient admitted medical/surgical as an in patient or swing bed patient..."

2. on 10/11/11 at 12:30 PM, while reviewing open medical/surgical and swing bed patient medical records N5 through N9, it was discovered that:
a. swing bed patient N6 lacked a "High Risk Fall Assessment" form completion on 10/8/11 (two page document on chart, but not completed)
b. medical/surgical patient N9 lacked a "High Risk Fall Assessment form completion on 10/9/11 (two page document on chart, but not completed)

3. interview with staff member NC at 11:25 AM on 10/13/11 indicated:
a. the policy 74350 (listed in 1. above) does not address daily completion of the "High Risk Fall Assessment" form by nursing staff, but daily fall risk assessment is the "practice" of the facility and should be completed for all patients

4. at 11 AM on 10/12/11, review of the policy and procedure "Documentation - Pediatric", PolicyStat ID 84138, indicated:
a. on page 2 under "A. Admission Assessment Form", it reads: "1. The admission assessment form is used to document the initial assessment. All areas in the form are to be completed...2....Absence of any defined parameter is considered a negative assessment and constitutes the use of a "0" in the category box..."

5. at 3:05 PM on 10/12/11, review of pediatric patient medical records (N19 to N21) indicated:
a. 3 year old pt. N20 had documentation by nursing on 2/27/11 at 23:25 hours that read the "Calc Height/Length Type/Method" was "stated", but had a "0" in the area of "Calc Height/Length (feet)..."

6. interview with staff member NC at 11:25 AM on 10/13/11 indicated:
a. the computerized preset/default areas of the admission/documentation portions of the medical record are to be completed by nursing staff
b. there was no height/length documented for pt. N20, and there should have been one noted

7. at 4:20 PM on 10/12/11, review of the policy "Blood Glucose by Accuchek Advantage Meter", PolicyStat ID 140508, indicated:
a. on page one under "Reagents", it reads: "...B. Accuchek Comfort Curve Control
Solutions, Level 1 and Level 2. When a new bottle of glucose control solution is opened, write the date opened on the label. Control solutions expire at 90 days after opening or the bottles's expiration date, whichever comes first. Write the expiration date on the bottles."

8. while on tour of the nursing units, the following was observed:
a. on 10/12/11 at 11:45 AM, while on tour of the surgery department's pre/post op area nurses' station in the company of staff members NC and NI, it was observed that the glucometer high and low control solutions had no date opened or dated of expiration written on the bottles, making it unknown when the 90 day expiration date will/or had occurred
b. on 10/12/11 at 2:30 PM, while on tour of the OB/nursery area in the company of staff members NC and NJ, it was observed that the glucometer high and low control solutions had an opened date written on the bottles that read: "3/24/11" and an expiration date of "6/24/11", but the solutions were still being utilized by nursing staff

9. interview with staff member NC at 4:30 PM on 10/12/11 indicated nursing staff are not following the blood glucose policy in relation to monitoring the open and expiration dates of the reagents

10. at 11:00 AM on 10/12/11, review of the policy and procedure "Telephone and Verbal Orders" PolicyStat ID 74877, indicted:
a. under "Rational:", it reads: "...It has always been a standard of care at SVRH (St. Vincent Randolph Health) that verbal communication of orders is confirmed in the manner described."
b. under "Implementation::", it reads: "...2. When the physician has indicated that the list of orders is completed, indicate to the physician that the orders will be repeated back. 3. Read all orders as written to confirm accuracy. 4. If the physician is unable or unwilling to confirm orders by listening to read-back, fax orders to physician for confirmation signature. 5. Orders not confirmed by reading orders back or by faxed signature will not be implemented...9. When signing off verbal or telephone orders, the person receiving the orders will document and sign that all orders were read back and confirmed."

11. review of open and closed patient medical records through out the survey process of 10/11/11 to 10/13/11, indicated:
a. pt. N6 had verbal orders (3) of 10/7/11 that were not documented as read back and verified, nor was there documentation of having been faxed to the physician for confirmation
b. pt. N14 had telephone orders of 10/10/11 and 10/11/11 that were not documented as read back and verified, nor was there documentation of having been faxed to the physician for confirmation
c. pt. N18 had orders of 8/19/11 written by nursing that read "TLRB"or "TORB"-(-unable to determine documentation), with no clear documentation of read back and verify, per policy
d. pt. N19 had telephone orders of 8/4/11 that were not documented as read back and verified, nor was there documentation of having been faxed to the physician for confirmation
e. pt. N21 had "T.O/V.O." by nursing staff on 9/13/11 that were not documented as read back and verified, nor was there documentation of having been faxed to the physician for confirmation

12. interview with staff member NC at 11:00 AM on 10/13/11 indicated:
a. verbal and telephone orders for patients N6, N14, N18, N19 and N21 were lacking read back and verified documentation by nursing staff as required by policy and procedure
b. it was unable to determine what the documentation by nursing for pt. N18 meant--what was documented was not an approved abbreviation

Based on review of policies/procedures manual and staff interview, the facility failed to have a policy/procedure that ensures the intergration of the food and dietetic service into hospital-wide Quality Assurance (QA) and Infection Control programs.

Findings included:

1. Review of dietary service policies and procedures on 10/13/2011 at 1:30 pm indicated the dietary service did not have a QA program or a policy/procedure that address dietary QA.

2. In interview on 10/11/2011 at 11:45 am, staff member J2 acknowledged the dietary service department did not actively participate in the hospital-wide QA meeting. In further interview on 10/12/2011 at 3:30 pm, staff member J5 acknowledged the following:
a. Dietary Service is not represented in the hospital QA and infection control committee meetings.
b. Hand hygiene practices were not being monitored in the dietary service department.

Based on document review and interview, the facility failed to review its patient care policies/procedures at least annually by a group that included at least one doctor of medicine (MD) or osteopathy (DO).
Findings:
1. Review of the facility policy Annual Policy Review (last reviewed 06-06) failed to require all patient care policy/procedures to be reviewed annually by an MD or DO in addition to a department manager, director or administrative representative.
2. Review of swing bed, radiology, respiratory therapy, and emergency department policy/procedures failed to indicate that an MD or DO had performed a review.
4. During an interview on 10-12-11 at 1340 hours, staff #A2 confirmed that the facility failed to require an MD or DO to review the patient care policy/procedures.

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to implement its policy related to creating and updating nursing care plans for 9 open and closed patient records reviewed, pts. N5 through N13, and failed to ensure physician's orders matched the nursing care plan for 1 of 1 OB (obstetric) patient chart reviewed (N18).

Findings:
1. at 1:10 PM on 10/11/11, review of the policy "Documentation Frequency Guidelines", with an Effective date of November 30, 2009, indicated:
a. under "Plan of Care.", it reads: "The plan of Care is to be initiated upon admission to the patient unit. Individualization should be added within four hours of patient's admission to the hospital. It is reviewed and updated once a shift and as needed by all disciples." (disciplines was meant)

2. Review of open and closed patient medical records indicated:
a. on 10/11/11 at 12:30 PM, while reviewing open medical/surgical and swing bed patient medical records N5 through N9, it was discovered that nursing staff could not access, on the computerized medical record, a nursing care plan for these patients or documentation of every shift review and updates
b. on 10/11/11 at 1:45 PM, an on line review of closed patient medical records N10 through N13 indicated no nursing care plans could be found by facility staff assisting with the review
c. at 12:15 PM on 10/12/11, review of patient medical record N18 indicated the patient had a C-Section on 8/19/11 with post operative orders that read: "...Bedrest X 2 h...Foley to gravity May dc (discontinue) when pt is stable and able to ambulate", but had a nursing care plan initiated at 12:24 AM on 8/20/11 that indicated: "...Encourage patient to be ambulating and up in chair as tolerated with assist as needed;..."

3. at 3:05 PM on 10/12/11, interview with staff member NJ indicated:
a. a corporate staff member has advised this staff member that the nursing care plan is a "working care plan" and not a permanent part of the medical record
b. currently, nursing staff are not documenting an every shift review and update, if needed
c. nursing chose the "default/normal" post delivery care plan for pt. N18, which encourages ambulation after delivery, instead of personalizing the care plan for a C-Section patient who wouldn't be up and ambulating for several hours after surgery

4. interview with staff member NC at 3:15 PM on 10/12/11 indicated:
a. there is no way to determine that nursing staff are reviewing the nursing care plan every shift or updating the care plan with changes in patient condition, per facility policy
b. it cannot be determined that all disciplines are reviewing and updating the care plan as per policy requirements
c. staff on the medical/surgical nursing unit report today that they are able to access the nursing care plan on the computer
d. the current computer system is not user friendly for nursing staff in creating a comprehensive nursing care plan that addresses all of a patient's problems and in allowing every shift documentation by nursing staff

Based on patient medical record review and staff interview, the facility failed to ensure the witnessing, or completion, of admission documents to swing bed status for 3 of 3 swing bed patient records reviewed while touring the nursing unit (N5, N6 and N7) and for one closed patient medical record (N10).

Findings:
1. at 12:00 PM on 10/11/11, while on tour of the nursing unit in the company of staff members NC and NF, and during closed patient medical record review, it was observed that:
a. during review of 3 open swing bed patient records, the presence of an "Admission Agreement" form (number 2051), that was signed by the patient or responsible party was noted, but the "Witness/Date" area of the forms was blank
b. pt. N7 was changed to swing bed status on 10/8/11 and had a blank consent to treat ("General Consent for Medical Services" form) on the medical record
c. pt. N10 had a blank consent to treat ("General Consent for Medical Services" form) on the medical record

2. interview with staff members NC and NG at 9:35 AM on 10/12/11 indicated:
a. the "General Consent for Medical Services" form is utilized for both acute care admission and then again when a patient is admitted to swing bed status
b. pt. N7 had a blank "General Consent for Medical Services" form in the medical record 3 days after admission to swing bed status
c. registration/patient access is to be notified by nursing staff of the change from acute care status to swing bed, and then to attain the consent signatures as required
d. if patient access is unable to accomplish the task of gaining consent signatures, they are to alert nursing staff to assist with this, it appears that there may be a break down in communication between these two groups
e. the "Admission Agreement" form is a form that is used specific to swing bed admissions (along with the "General Consent for Medical Services" form )
f. it was unknown by staff member NG that a witness signature was needed on the "Admission Agreement" form, even though this document indicates patients are notified of financial information related to their swing bed status and that lack of witness authentication leaves one to be unsure what staff member instructed the patient regarding this
g. the facility policy and procedure related to "Consent to Treat", does not address the consent requirements for admission to swing bed status in relation to the "General Consent for Medical Services" form, or the "Admission Agreement" form

Based on review of medical staff rules and regulations, open and closed patient medical record review, and staff interview, the facility failed to ensure that history and physicals were performed within 24 hours, as required, for 1 of 4 open swing bed patients (N7) and 1 of 3 closed pediatric medical records (N21) and that history and physical reports are authenticated within 24 hours of dictation for 1 of 3 closed pediatric patient records (N21).

Findings:
1. at 9:20 AM on 10/11/11 and 12:25 PM on 10/13/11, review of the medical staff rules and regulations, dated approved on July 2010, indicated:
a. on page 17, it reads: "...A complete history and physical should be dictated within 24 hours of inpatient admissions...All history and physical should be signed within 24 hours of dictation."

2. Review of patient open and closed medical records through out the survey process of 10/11/11 to 10/13/11 indicated:
a. pt. N7 was discharged from acute care to swing bed status on 10/8/11 and as of 12:00 PM on 10/11/11, had no admission history and physical, either dictated or present, in the current swing bed record
b. pt. N21:
A. was admitted on 9/12/11 and had a history and physical with a dictated date of 9/14/11
B. had a transcription date of 9/14/11
C. had authentication by the physician, with an electronic signature, of 10/10/11

3. interview with staff members NA, NG, and NC at 11:00 AM on 10/13/11 indicated:
a. physicians may use the patient's acute care discharge summary for a swing bed history and physical, with a note indicating thus, and authenticated within 24 hours of admission to swing bed status
b. pt. N7 had no discharge summary or other documentation of a history and physical, only a progress note stating a change of status to swing bed from acute care
c. physicians indicate that at times the transcribed history and physical are not on the chart and available for authentication within 24 hours of the dictation
d. the history and physical for pt. N21 was not dictated within 24 hours, as required by medical staff rules and regulations
e. the history and physical for pt. N21 was transcribed the day of dictation (9/14/11) and not authenticated until 10/10/11, not within 24 hours of dictation, as required by the medical staff rules and regulations

Based on review of the medical staff rules and regulations, patient medical record review, and staff interview, the medical staff failed to implement its rules and regulations related to: dating and timing all authentication in the medical record for 3 patient records reviewed (N14, N20 and N21); and related to authentication of telephone and verbal orders within 24 hours for 5 patient records reviewed (N6, N7, N14 and N21).

Findings:
1. at 9:20 AM on 10/11/11 and 12:25 PM on 10/13/11, review of the medical staff rules and regulations, dated approved on July 2010, indicated:
a. on page 17, under "Policy", it reads: "...All entries are to be timed, dated, and authenticated by the person making the entry..."
b. on page 19, under "Policy", it reads: "...Verbal orders should be countersigned by the prescribing physician within 24 hours..."

2. Review of patient medical records through out the survey process of 10/11/11 to 10/13/11 indicated:
a. pt. N6 had verbal orders noted on 10/7/11 at "1010" that were not authenticated by the practitioner as of 10/11/11
b. pt. N7 had telephone orders of 10/7/11 at "1645" that were not authenticated by the practitioner as of 10/11/11 and verbal orders on 10/8/11 at 2300 hours that were not authenticated by the practitioner as of 10/11/11
c. pt. N14 had telephone orders on 10/10/11 at 1400 hours that were not authenticated by the practitioner as of 10/12/11
d. pt. N14 had telephone orders on 8/19/11 at 2200 hours and on 8/20/11 at 2115 hours that were authenticated by the practitioner, but were lacking a date and time of authentication, as required by the medical staff rules and regulations, making it unclear if they were signed within the 24 hours also required by medical staff rules and regulations
e. pt. N19 had telephone orders of 8/4/11 at 1620 hours and 8/6/11 at 1000 hours that were authenticated electronically on 8/17/11 and 8/19/11 respectively, and not within the 24 hours required by medical staff rules and regs
f. pt. N20 had standing physician admission orders on 2/27/11 that were authenticated, but lacked a date and time of authentication as required by medical staff rules and regulations
g. pt. N21 had:
A. telephone orders of 9/12/11 at 2100 hours and on 9/13/11 at 1213 hours that were authenticated electronically on 10/10/11
B. telephone orders of 9/13/11 (no time of order noted), that were authenticated by the practitioner, but lacked a date and time of authentication as required by medical staff rules and regulations

3. interview with staff member NC at 12:30 PM on 10/3/11 indicated:
a. a deficiency related to physician's lack of authenticating verbal and telephone orders within 24 hours was also cited in the 2010 licensure survey of the facility
b. it cannot be determined that appropriate monitoring and disciplinary actions are happening related to the inclusion of a date and time with physician authentication and related to authentication of telephone and verbal orders within 24 hours

Based on document review and interview, the facility failed to perform an annual review of its health care policies/procedures at least annually.
Findings:
1. The administrative policy Annual Policy Review (last reviewed 06-06) indicated the following: Annually all policies will be reviewed ...[and] ...This documentation may be in the form of a signed page documenting which policies were reviewed; or the documentation of review may be done on each policy in a manual.
2. During an interview on 10-13-11 at 0930 hours, staff #A14 confirmed that the facility policy/procedures had not been reviewed annually and indicated that all policies and procedures would be up to date before 2012.

Based on review of the patient rights document, open swing bed patient medical record review, and staff interview, the facility failed to ensure that patients are informed of their rights as a swing bed patient for 4 of 4 patients. (N5, N6, N7 and N14)

Findings:
1. Review of patient medical records through out the survey process of 10/11/11 to 10/13/11 indicated:
a. there was no documentation indicating that patients were informed of their specific swing bed patient rights for patients N5, N6, N7 and N14 either prior to, or at the time of, admission

2. at 9:30 AM on 10/12/11, review of the patient rights document, "St. Vincent Patient Rights and Responsibilities", indicated that swing bed specific patient rights are not included in this document

3. at 9:35 AM on 10/12/11, interview with staff members NC and NG indicated:
a. the current patient rights document, that is provided to patients on admission, does not address swing bed specific patient rights, such as: notification prior to transfer, patient activities, social services and discharge planning, the ability to be notified of and to attend care planning meetings, the ability to receive emergency dental care, and other services
b. it cannot be determined, due to lack of documentation in the medical record, that swing bed patients are informed of their swing bed patient rights prior to admission as a swing bed patient
c. the facility was also cited related to this issue with the last validation survey in 2008

Based on medical record review and staff interview, the facility failed to ensure that swing bed patients were advised, at the time of admission, of items or services that the resident may be charged for, and the amount of those charges, for 7 open and closed swing bed patient records reviewed. (N5, N6, N7, and N14 through N17)

Findings:
1. review of open and closed swing bed patient medical records during the survey process of 10/11/11 to 10/13/11 indicated:
a. pts. N5, N6, N7, and N14 through N17 had a form titled "Admission Agreement" that states: "...the Medicare Law only pays for Skilled Nursing Facility (SNF) level of care...", but does not alert the patients to any items or services that will not be covered and what the costs of those items/services would be

2. at 9:35 AM on 10/12/11, interview with staff member NG indicated the "Admission Agreement" form does not make it clear to patients and families what, if any, out of pocket charges may be the patient's responsibility as a swing bed patient

Based on patient medical record review, review of multidisciplinary care plan notes/attendance sheets, and staff interview, the facility failed to create interdisciplinary, comprehensive care plans for 4 of 4 current swing bed patients. (N5, N6, N7 and N14)

Findings:
1. Review of patient medical records through out the survey process of 10/11/11 to 10/13/11 indicated:
a. pts. N5, N6, N7 and N14 were lacking a comprehensive care plan present in the medical record

2. at 10:45 AM on 10/13/11, review of the "Multidisciplinary Team Meeting" notes/attendance forms for various months, including, but not limited to, February 2011, April 2011 and August 2011, it was indicated that:
a. on the front page of the forms, it reads "Per Physician direction cont current POC (plan of care)"; "See Quest (computerized) Documentation"; and "Continue P.O.C. per physician direction"

3. interview with staff member NG at 9:35 AM on 10/12/11 indicated:
a. the nursing care plan is utilized for the multidisciplinary/comprehensive care plan, thus the wording "cont with poc", meaning the nursing care plan (to see Quest documentation also means the nursing care plan)
b. there is no care plan, based on the various disciplines and their specific goals/objectives, created for swing bed patients
c. the facility has no policy related to comprehensive care plans for swing bed patients

Based on review of facility policy and procedure, multidisciplinary care plan notes/attendance sheets, and staff interview, the facility failed to implement its policy related to the frequency of multidisciplinary team meetings and failed to ensure compliance with attendance at the meetings that were cunducted for review and revision of the plans of care, by specified team members, for three of three patients who were swing bed patients in February, April and August for 2011 (N15, N16 and N17), and for four current swing bed patients (N5, N6, N7 and N14).

Findings:
1. at 10:45 AM on 10/13/11, review of the policy "Multidisciplinary Team Meetings" with PolicyStat ID 73344, indicated:
a. under "Preparation:", it reads: "The Multidisciplinary Team will consist of the following disciplines within the hospital: Social Services/Discharge Planning--Nursing--Respiratory Care--Dietary--Rehabilitation/Therapy--Infection Control--Pharmacy--Chaplain/Spiritual Services--the Provider will participate if available and will be asked to read the communication form and sign."
b. under "Implementation", it reads: "The Multidisciplinary Team will meet three times a week and are asked to participate actively in the case study and discussion of each patient's care..."
c. under "Documentation", it reads: "Documentation of these team meetings will be made on the Care Team Communication Form and be kept on the patient chart..."

2. at 10:45 AM on 10/13/11, review of the "Multidisciplinary Team Meeting" notes/attendance forms for various months, including, but not limited to, February 2011, April 2011 and August 2011, indicated that:
a. pt. N15:
A. was admitted to swing bed status on 2/2/11 and discharged 2/10/11
B. was discussed at two multidisciplinary meetings on 2/4/11 and 2/7/11, with no meeting held on 2/9/11
C. was lacking the documentation at the 2/4/11 meeting of any discipline's presence on the "Multidisciplinary Team Meeting" notes/attendance form (per computer notes by the discharge planner, there was no chaplain, pharmacy staff or nursing staff present)
D. was lacking a chaplain, respiratory staff member or pharmacy presence at the 2/7/11 meeting

b. pt. N16 was admitted to swing bed status on 4/14/11 and discharged on 4/20/11 and had:
A. documentation of two multidisciplinary team meetings on 4/15/11 and 4/18/11
B. was lacking a chaplain or respiratory staff presence at the 4/15/11 meeting
C. was lacking chaplain presence at the 4/18/11 meeting

c. pt. N17 was admitted to swing bed status on 8/8/11 and discharged on 8/26/11 and had:
A. documentation of multidisciplinary team meetings on 8/8/11, 8/10/11, 8/15/11, 8/17/11, 8/19/11, and 8/22/11
B. was lacking documentation of a meeting on 8/12/11 and did not have a "Multidisciplinary Team Meeting" notes/attendance form for 8/24/11 making it impossible to tell if a meeting occurred, or what staff did, or did not, attend if there was a meeting
C. was lacking the presence of pharmacy, respiratory or the chaplain on 8/8/11
D. was lacking the presence of respiratory, physical or occupation therapy staff, or the chaplain on 8/10/11 and 8/15/11
E. was lacking the presence of respiratory and pharmacy on 8/17/11
F. was lacking the presence of dietary, pharmacy and infection control on 8/19/11
G. was lacking the presence of respiratory, physical or occupation therapy staff, or dietary staff on 8/22/11

3. interview with staff member NG at 11:00 AM on 10/12/11 indicated:
a. there was no multidisciplinary meeting held yesterday, 10/11/11, for current swing bed patients (4 patients-N5, N6, N7 and N14) due to the absence of the discharge planner
b. there was no multidisciplinary meeting on 2/9/11 or 8/12/11
c. the policy states that meetings will occur 3 times a week, but there are occasions when this has not occurred
d. there is no provision in the policy for lack of attendance by various disciplines if they are unable to attend the three times a week multidisciplinary team meetings
e. none of the patients above (N5, N6, N7, N14, N15, N16 and N17) had the form titled Care Team Communication Form in their medical records
f. there is no longer a form titled Care Team Communication Form, but the policy has not been updated related to this
g. there is no place in the computerized/electronic patient record for various disciplines to be able to "sign" regarding input into the multidisciplinary meetings, or to indicate their presence at a meeting