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Based on observation, interview and record review facility Dietary and Housekeeping staff failed to ensure a sanitary environment was maintained with easily cleanable surfaces including the heavily marred and breached floor surface in the facility kitchen. The facility census was 12.

Findings included:

1. Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 6-101.11 Surface Characteristics showed direction for the facility to ensure materials for indoor floors shall be smooth, durable and easily cleanable.

Record review of an undated facility environmental services (housekeeping) policy titled, "Criteria for Quality Standards" showed direction for staff to ensure the following:
-Floor surfaces were in good repair.
-Report loose tile or other floor damage immediately.

2. Observation on 12/28/11 from 11:05 AM through 11:46 AM in the facility kitchen showed sections of the floor covering with multiple holes and gouges in the surface that were rimmed with imbedded blackened food and unknown debris.

3. During an interview on 12/28/11 at 11:26 AM Staff Y, Cook stated the kitchen floors were difficult to successfully clean due to the damage to the surface.

4. During an interview on 12/29/11 at 10:30 AM Staff HH, Director of Housekeeping confirmed the following:
-Housekeeping staff were responsible for cleaning the facility kitchen floor.
-She would expect the Housekeeping staff to inform her about chips or breaks in the tile surface of the floor.

Based on observation and interview, the facility failed to ensure medications on the Medical/Surgical Unit were kept in a locked, secured area to prevent unauthorized access to any staff, patients or visitors on the unit. The facility census was 12.

Findings included:

1. Observation on 12/28/11 at 8:40 AM showed Staff CC, Registered Nurse (RN), preparing to administer medications from a medication cart contained the medication of six patients. Staff CC used a set of keys to open a medication cart located in the nursing station area, and discovered that she needed additional medication from the Omnicell (an automated medication dispensing machine), which was located in a different area. Without locking the cabinet and removing the keys, Staff CC went to retrieve the necessary medications. When she returned to the cart approximately five minutes later, the cart and keys were gone. Staff CC went from room to room searching for the medication cart before discovering (after approximately 10 minutes) that another nurse had taken the cart and keys to pass medications to other patients.

Observation on 12/28/11 at 9:00 AM showed Staff CC administering medications to Patient #20. After scanning each medication into the Medication Administration Record, Staff CC discovered that two medications were missing. Staff CC gathered all the medications she had just scanned for 9:00 AM administration and placed them back into the medication bin for Patient #20, then took that bin to the Medication Room. Staff CC left two medications scheduled for a different administration time on the counter in Patient #20's room while she went to retrieve the missing 9:00 AM medications.

2. During an interview on 12/28/11 at 10:30 AM, Staff E, Nurse Manager for the Medical/Surgical Unit, made the following statements:
- Staff CC should have locked the cart before walking away from it, even though it was near the nursing station.
- Medications should not have been left unattended in a patient room.
- Staff CC was an Obstetric Unit nurse who was working on the Medical/Surgical Unit due to the Obstetric Unit being empty.
- "Float nurses" (staff who work in a unit different from their usual assignment) receive training regarding the work flow of each unit they "float" to, and they spend a period of time working with mentor (a nurse regularly assigned to that unit) before being allowed to work alone.

During an interview on 12/29/11 at 10:00 AM, Staff D, Nurse Educator, made the following statements:
- Nursing staff are trained on key control, and are trained not to leave medications unsecured.

Based on observation, interview, and policy review, facility nursing staff failed to follow hand hygiene and gloving guidelines to prevent the risk of transmission or organisms for three patients (#5, #18, and #20) of five patients observed during nursing procedures; and facility dietary staff failed to perform appropriate hand hygiene and gloving during food preparation. The facility census was 12.

Findings included:

1. Record review of the facility's policy titled "Hand Hygiene," revised 08/11, showed the following direction:
Hospital personnel shall wash their hands to prevent the spread of infections:
- When entering and leaving a patient room (FOAM IN/FOAM OUT)
- Before applying and removing gloves
- Before contact about the face and mouth of patients
- After handling inanimate objects (including medical equipment) in the immediate vicinity of the patient.
- Before moving from a contaminated body site to a clean body site during patient care.

2. Observation on 12/28/11 from 8:45 AM through 9:30 AM showed Staff CC, Registered Nurse (RN) administering medications to Patient #20.
- One of Patient #20's medications required that the pill be broken in half. Without performing hand hygiene or applying gloves, Staff CC removed the pill from its packet and broke it in half with her fingers.
- Without performing hand hygiene or applying gloves, Staff CC administered eye drops to each of Patient #20's eyes.
- Without performing hand hygiene or applying gloves, Staff CC prepared and administered intravenous (IV) medication for Patient #20.
- Staff CC left Patient #20's room to obtain additional medications for administration. Upon returning to Patient #20's room, Staff CC failed to perform hand hygiene upon entering the room and before continuing with medication preparation and administration.
- Staff CC applied gloves before placing adhesive medication patches on Patient #20's body, but failed to perform hand hygiene after removing her gloves.

3. During an interview on 12/27/11 at 10:30 AM, Staff E, RN Nurse Manager for the Medical/Surgical Unit made the following statements:
- Nursing staff are expected to wear gloves when administering eye drops, but are not expected to wear gloves when administering IV medications.
- Nursing staff should use a pill cutter when a pill needs to be split. If a pill cutter is not available, the nurse should wear gloves when splitting the pill by hand.

During an interview on 12/29/11 at 10:00 AM, Staff D, Nurse Educator, made the following statements:
- Nursing staff are trained to perform hand hygiene when entering and leaving patient rooms, and after touching a patient.
- Nursing staff are trained to wear gloves when touching a patient and to perform hand hygiene after removing gloves.
- Nursing staff are trained to wear gloves when administering eye drops, ear drops, and IV medications.

During an interview on 12/29/11 at 10:15 AM, Staff CC stated the facility did not have a specific guideline/procedure for nurses to follow in regard to splitting pills, hand hygiene during medication administration, when to apply gloves during medication administration, etc.

4. Observation on 12/28/11 at 8:43 AM in Patient #18's room showed Staff EE, Orthopedic Surgeon put on gloves and removed the dirty dressing from the patient's left foot toe amputation. He then palpated (felt) the foot wearing the same gloves. Wearing the soiled gloves, he placed telfa on the wound and wrapped the ankle and foot with kerlix. He did not perform hand hygiene or replace his gloves between the removal of the dirty dressing and the placement of the clean dressing.

Observation on 12/28/11 at 9:00 AM in Patient #18's room showed Staff J, RN put on gloves and removed the dressing on the patient's right heel and then crossed the room and opened a drawer to retrieve a plastic bag in which to place the dirty dressing. She did not remove the gloves and perform hand hygiene after removing the dirty dressing and before she touched objects in the room. Wearing the same dirty gloves, she then removed the 2x2 gauze from the pressure sore on the heel and placed it in the plastic bag.

Observation on 12/28/11 at 9:15 AM in Patient #18's room showed Staff L, RN, put on gloves and cleansed a sore on Patient #18's right heel. Staff L wore the same soiled gloves and applied Santyl (a medicine which is used to remove dead tissue from wounds), telfa (a non stick dressing) and a kerlix wrap (a roll of stretchy gauze) dressing. Staff L did no hand hygiene or change of gloves between the dirty and clean dressings.

During an interview on 12/29/11 at 8:45 AM Staff J, RN, stated that she didn't realize she had not removed her gloves and did not wash her hands between removing the dressings and touching objects in the room. Staff J stated that she should have removed her gloves and washed her hands before touching anything else in the room.

During an interview on 12/29/11 at 8:55 AM Staff L, RN, stated that she didn't know she hadn't washed her hands or regloved between the dirty and clean dressings until interviewed by the surveyor. She stated that she knew she was supposed to wash her hands and reglove between the dirty and clean dressings.

5. Observation on 12/28/11 at 9:44 AM in Patient #5's room showed Staff FF, Certified Nurse Assistant (C.N.A), performed peri care (the cleansing of the patients genitalia) on the patient. Staff FF wore the same dirty gloves she used for peri care, repositioned the patient to his side and touched his back and gown.

Observation on 12/28/11 at 9:55 AM in Patient #5's room showed Staff J, RN, removed a dirty dressing from a wound on the left arm of the patient. This wound was identified as having Methacillin Resistant Staph Aureus (MRSA), an infection caused by a strain of bacteria. Staff J performed hand hygiene and put on gloves. She cleansed the wound area with normal saline and placed telfa, 4x4 gauze and kerlix wrap on the wound. Staff J, RN, did not perform hand hygiene or change her gloves between the cleansing of the wound and the placement of the clean dressings.

During an interview on 12/28/11 at 2:50 PM Staff N, Infection Control Officer, stated that she would expect the C.N.A. to take her gloves off and wash her hands when going from a dirty area to a clean area. Staff N stated that she would expect nursing to take their gloves off and wash their hands after removing the dirty dressings and before placing the clean dressings on a wound.

6. Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 3-304.15 Limitation of glove use showed direction for dietary staff to use single use gloves for one task only and discard when damaged, soiled or when there was an interruption in the operation.

Record review of the facility dietary policy titled, "Gloving" reviewed in 07/11 showed the following direction:
-Gloves should be disposed of when they were obviously soiled, have come in contact with a contaminated surface or in contact with skin, face, hair, etc,.
-Gloves were not to take the place of good hand washing techniques.

Record review of the facility infection control/dietary policy titled, "Hand Hygiene" revised in 07/11 showed direction for facility staff to wash their hands before applying and after removing gloves.

7. Observation on 12/28/11 at 11:34 AM in the facility kitchen showed Staff X, Cook with gloved hands, retrieved a plastic canister she'd dropped on the floor, placed it on a cart then without removing soiled gloves and washing hands, gathered serving utensils to use for patient noon meal service.

Observation on 12/28/11 at 11:40 AM in the facility kitchen showed Staff W, Diet Aide placed a gloved hand (palm down) on the cook's table then, without removing soiled gloves and washing hands, served beverages on patient meal trays.

Observation on 12/28/11 at 11:42 AM in the facility kitchen showed Staff Y, Cook placed a gloved hand (palm down) on the cook's table then, without removing soiled gloves and washing hands, served garnishes and handled plated foods for patient meal service.







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27727

Based on observation, interview and record review the facility
-Dietary staff failed to follow recognized food sanitation standards and facility policy to protect stored foods and stored disposable cups (used in patient meal service) from cross contamination.
-Staff failed to follow facility policy to ensure the approved diet manual was available to all staff for use as a diet reference for inpatient care.

The facility census was 12.

Findings included:

1. Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 3-305.11 Food Storage showed direction for facility dietary staff to store foods in clean, dry locations, not exposed to splash, dust or other contamination at least fifteen inches above the floor.

Record review of the facility policy titled, "Receiving, Storage" reviewed in 07/11 showed direction for facility dietary staff to store food items on shelves twelve inches above the floor.

2. Observation on 12/27/11 at 3:14 PM showed dietary staff stored a case of disposable cups on the floor of the dry foods storeroom.

During an interview on 12/27/11 at 3:14 PM Staff G, Director of Dietary confirmed the case of cups were routinely stored on the floor.

3. Observation on 12/27/11 at 3:20 PM showed dietary staff stored a case of margarine and a case of four bulk containers of cottage cheese on the floor of the walk-in refrigerator.

During an interview on 12/27/11 at 3:20 PM Staff G confirmed the margarine and the cottage cheese were routinely stored on the floor of the walk-in refrigerator.

4. Record review of the facility policy titled, "Diet Manual" revised in 07/11 showed the following direction:
-The American Dietetic Association's Nutrition Care Manual was used as the basis for planning menus, diets and diet instructions.
-The facility physicians were urged to order diets with terminology used in the Nutrition Care Manual.
-The Nutrition Care Manual was available on-line and could be accessed through any facility computer as needed by physicians and nursing staff.

5. During an interview on 12/27/11 at 2:40 PM Staff G, Director of Dietary stated the facility diet manual was on-line and was accessible by all staff.

6. During an interview on 12/28/11 at 9:05 AM Staff I, Unit Secretary stated she did not know where the facility diet manual was located.

7. During an interview on 12/28/11 at 9:40 AM Staff H, Swing Bed Nurse looked for the diet manual in a book shelf in the nurses' station then, confirmed she did not know where the facility diet manual was located.

Based on observation, interview, record review, and policy review, the facility failed to individualize and update nursing care plans for one patient (#19) of two acute care patients reviewed for Care Plans. The facility census was 12.

Findings included:

1. Record review of the facility's policy titled, "Admission Assessment and Discharge Planning," effective 05/09, showed the following directions:
- Outcomes identification:
- The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation.
- 7. Modifies expected outcomes based on changes in the status of the patient or evaluation of the situation.
- Planning:
- The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
- Develops an individualized plan considering patient characteristics of the situation.
- Includes strategies within the plan that address each of the identified diagnoses or issues, which may include strategies for promotion and restoration of health and prevention of illness, injury, and disease.
- Utilizes the plan to provide direction to other members of the healthcare team.

NOTE: The facility did not provide a care plan policy that specifically addressed care plans for acute care patients.

2. Record review of Patient #19's medical record on 12/28/11 at 9:43 AM showed the following:
- Documentation dated 12/26/11 at 6:50 AM showed Patient #19 got out of bed unassisted to use the restroom. Upon returning to his bed, Patient #19 felt weak and lowered himself to the floor.
- A Nutritional Assessment dated 12/27/11 noted that the patient's appetite had been decreased and that he had been started on an appetite stimulant. Goals and recommendations were documented as follows:
Goals:
- Patient to eat greater than 75% of meals
- Increase weight
- Increase albumin (a protein found in blood that is used to determine malnutrition)
Recommendations:
- Selective menu for patient preference
- Encourage oral intake and assist with meals
- Nutritional supplements
- Monitor intake and weight

3. Review of the Care Plan for Patient #19 on 12/28/11 at 10:15 AM showed the following "problems" were identified:
- Infection Potential (in regard to) Intravenous (IV) access
- Altered Respirations
- Pain

Information regarding the patient's fall on 12/26/11 and subsequent addition of Fall Risk Precautions on 12/27/11 was not added to Patient #19's Care Plan, and recommendations from the Nutritional Assessment on 12/27/11 were not included in the Care Plan.

4. During an interview on 12/28/11 at 10:35 AM, Staff E, Nurse Manager for the Medical/Surgical Unit, stated that the Care Plan for Patient #19 should have been updated to include the fall precautions initiated on 12/27/11.

During an interview on 12/28/11 at 12:50 PM, Staff G, Directory of Dietary, stated that dietary goals were not included on the nursing Care Plan, but were available in the chart for review. Staff G stated she attended "rounds" each morning with patient physicians, the Nurse Manager, and nurses assigned to care for the patients, and that dietary information was conveyed as indicated to these individuals. Staff G stated it was possible to add dietary goals to the nursing Care Plan so that all levels of nursing staff were be aware of them, but it was not a standard practice.

During an interview on 12/28/11 at 12:55 PM, Staff E stated that nursing technicians were not included during "rounds," and that unless specific information was conveyed to them, they probably would not know to encourage the patient to eat or drink fluids, and probably would not assist the patient with his meals. Review of the documentation provided to nursing technicians regarding patient care assignments at shift change did not show evidence that this information was conveyed through assignment documentation.

Based on Missouri State Statute review, personnel record review and interview the facility failed to:
-Ensure individuals listed on the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) were not employed by the facility.
-Request a criminal background check (CBC) prior to allowing any person who had been hired to have contact with a patient or resident.

Record review of ten (Staff E, G, L, P, Q, R, S, T, U, and V) of ten facility staff showed the facility failed to compare the names of staff on hire and on a periodic basis against the EDL and the facility failed to obtain a CBC on all but Staff R.

The facility census was 12.

Findings included:

1. Review of the Missouri State Statutes showed the following:
-RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks but also periodic checks of all existing staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (The quarterly updated EDLs are available on the Missouri Department of Health and Senior Services web site).
-RSMO 2003 Section 660.317 (3) (1) directed facilities licensed under Chapter 197 (hospitals) to request a criminal background check for any person who had been hired for a full-time, part-time, or temporary position, prior to allowing the new hire to have contact with a patient or a resident.

2. Record review of Staff G, Director of Dietary's personnel file showed Staff G:
-Had been employed in the facility since 06/02/80.
-Had not had verification that she was not on the EDL on hire.
-Or periodically since hire.
-Had not had a CBC done.

Record review of Staff T, Dietary Supervisor's personnel file showed Staff T:
-Had been employed in the facility since 08/15/94.
-Had not had verification that she was not on the EDL on hire.
-Or periodically since hire.
-Had not had a CBC done.

Record review of Staff U, Assistant Director of Health Information Management's (HIM) personnel file showed Staff U:
-Had been employed in the facility since 09/04/62.
-Had not had verification that she was not on the EDL on hire.
-Or periodically since hire.
-Had not had a CBC done.

Record review of Staff V, Director of HIM's personnel file showed Staff V:
-Had been employed in the facility since 09/27/73.
-Had not had verification that she was not on the EDL on hire.
-Or periodically since hire.
-Had not had a CBC done.

Record review of Staff E, Medical/Surgical Manager's, personnel file showed Staff E:
-Had been employed in the facility since 04/19/99
-Had not had verification that she was not on the EDL on hire.
-Or periodically since hire
-Had not had a CBC done.

Record review of Staff L, Registered Nurse's, personnel file showed Staff L:
-Had been employed in the facility since 08/20/07
-Had not had verification that she was not on the EDL periodically since hire
-Had not had a CBC done.

Record review of Staff P, Certified Registered Nurse Anesthetist's, personnel file showed Staff P:
-Had been employed in the facility since 12/21/04
-Had not had verification that she was not on the EDL on hire.
-Or periodically since hire
-Had not had a CBC done.

Record review of Staff Q, Registered Nurse's, personnel file showed Staff Q:
-Had been employed in the facility since 06/24/81
-Had not had verification that she was not on the EDL on hire.
-Or periodically since hire
-Had not had a CBC done.

Record review of Staff R, Housekeeping's, personnel file showed Staff R:
-Had been employed in the facility since 07/07/11
-Had not had verification that she was not on the EDL on hire.
-Or periodically since hire.

Record review of Staff S, Registered Nurse's, personnel file showed Staff S:
-Had been employed in the facility since 08/05/74-Had not had verification that she was not on the EDL on hire.
-Or periodically since hire
-Had not had a CBC done.

3. During an interview on 12/28/11 at 12:50 PM Staff M, Assistant Vice President of Human Resources, stated that Human Resources does not annually check employees against the EDL. Staff M stated that he would ask nursing administration if they do the EDL checks.





27727

Based on interview, record review and policy review the facility failed to provide an ongoing program of activities based on comprehensive assessment of each patient's interests and the physical, mental and psychosocial well-being of the patient for three (#5,#6 and #7) of seven Swing Bed medical records reviewed. The facility census was 12 with seven of those patients in Swing Beds.

Findings included:

1. Record review of the facility policy titled "Activity Program" reviewed 01/11 showed the following direction:
-The Activity Director or designee will complete Initial Activity Assessment.
-The qualifying criteria for skilled care are such that, in most cases, planned activities for the patient will necessarily be confined to ones which can be done in the room.

2. Record review of Patient #5's History and Physical (H&P) dated 12/05/11 showed the patient was admitted to the facility after a neck fracture and for MRSA of the left forearm wound for aggressive antibiotic therapy and physical therapy.

Record review of Patient #5's medical record showed an initial assessment which was completed by nursing on 12/17/11. No activity initial assessment was found

Record review of Patient #5's "Skilled Nursing Program - Activity Checklist" dated from 12/19/11 through 12/26/11 with no documented time of day showed thirteen preprinted activities such as family visits, clergy visits, TV provided, radio provided, conversation, pet therapy etc. The staff assessed if the patient participated in any of these activities and made check marks or brief comments in some of the boxes opposite these activities. The form was signed by the Activities Director and dated 12/17/11 thru (no date given).

Record review of the "3-11 Skilled Nursing Activity Checklist" dated 12/17/11 through 12/28/11 showed fourteen activities such as family/friends visit, TV, Crafts/Hobby/Art, Games (board, cards, electronics) etc. The form showed these activities were from the information of interest from the Initial Assessment. No Activities Initial Assessment was found in the record. This form was signed by the Certified Nurses Asssistant (C.N.A.).

3. Record review of Patient #6's H&P dated 12/02/11 showed the patient was admitted to a swing bed for physical therapy after a fractured right hip.

Record review of Patient #6's medical record showed an initial assessment was completed by nursing on 12/01/11. No activity initial assessment was found

Record review of Patient #6's "Skilled Nursing Program - Activity Checklist" dated from 12/02/11 through 12/26/11 with no documented time of day showed thirteen preprinted activities such as family visits, clergy visits, TV provided, radio provided, conversation, pet therapy etc. The staff assessed if the patient participated in any of these activities and made check marks or brief comments in some of the boxes opposite these activities. The form was signed by the Activities Director and dated 12/01/11 through 12/23/11.

Record review of the "3-11 Skilled Nursing Activity Checklist" dated 12/01/11 through 12/28/11 showed fourteen activities such as family/friends visit, TV, Crafts/Hobby/Art, Games (board, cards, electronics) etc. The form showed these activities were from the information of interest from the Initial Assessment. No Activities Initial Assessment was found in the record. This form was signed by the C.N.A's.

4. Record review of Patient #7's H&P dated 12/22/11 showed the patient was admitted to a swing bed for continuation of physical therapy after surgery.

Record review of Patient #7's medical record showed an initial nursing assessment was completed by nursing on 12/22/11. No activity initial assessment was found

Record review of Patient #7's "Skilled Nursing Program - Activity Checklist" dated on two days, 12/23 (no year) and 12/26 (no year) with no documented time of day showed thirteen preprinted activities such as family visits, clergy visits, TV provided, radio provided, conversation, pet therapy etc. The staff assessed if the patient participated in any of these activities and made check marks or brief comments in some of the boxes opposite these activities. The form was signed by the Activities Director and dated 12/22/11.

Record review of the "3-11 Skilled Nursing Activity Checklist" dated 12/01/11 through
12/28/11 showed fourteen activities such as family/friends visit, TV, Crafts/Hobby/Art, Games (board, cards, electronics) etc. The form showed these activities were from the information of interest from the Initial Assessment. No Activities Initial Assessment was found in the record. This form was signed by the C.N.A's.

5. During an interview on 12/28/11 at 10:15 AM Staff O, Resident Activities Director, stated that she reviews the initial nursing assessment on the patient's medical chart for information about the patient. Staff O stated that there was not a separate assessment which she did for the patient's activity interests. Staff O stated that she did not have an event calendar anymore. Staff O stated that she did not have planned individualized activities for each of the residents.

During an interview on 12/28/11 at 2:15 PM Staff JJ, Registered Nurse (RN), stated that she did not know what planned activities were for any patient. She stated that there used to be a board hanging on the wall of the old unit with times and activities but it wasn't brought to the new unit which was opened a year or so ago.

Based on interview, record review and facility policy review the facility failed to develop and/or keep current plans of care to ensure patient care, treatment and /or services were appropriately planned to meet the patient needs for four (#5,#6,#7 and #18)of seven swing bed patients. The facility census was 12.

Findings included:

1. Record review of the facility policy titled, "Admission Assessment and Discharge Planning" effective 05/09, showed the following direction:
- The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation.
- Modifies expected outcomes based on changes in the status of the patient or evaluation of the situation.
- The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
- Develops an individualized plan considering patient characteristics of the situation.
- Includes strategies within the plan that address each of the identified diagnoses or issues, which may include strategies for promotion and restoration of health and prevention of illness, injury, and disease.
- Utilizes the plan to provide direction to other members of the healthcare team.

Record review of the facility's policy titled, "Guidelines Regarding Skilled Nursing Interdisciplinary Care Plan" reviewed 01/11, showed the following direction:
- An interdisciplinary care plan will include a functional team goal with a timetable to meet the resident's medical, nursing, mental, and psychological needs that are identified in the comprehensive assessments.
- The care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being.

2. Record review of Patient #5's medical chart showed the patient was admitted to the swing bed on 12/17/11 for a left arm infection with Methicillin Resistant Staph Aureus (MRSA), a bacterial infection, and a fractured left hip. The patient was in Contact Isolation (safety procedures such as wearing gowns, gloves and/or masks that prevent specific germs from spreading in the hospital) due to the MRSA. In addition the record showed the patient had a diagnosis of Diabetes and decreased appetite.

Record review on 12/28/11 Patient #5's plan of care showed no documentation of an individualized plan of care based on the diagnosis and/or assessment and did not include personal goals and/or interventions regarding the patient's Contact Isolation status, diagnosis of Diabetes and the plan of care for decreased appetite had no interventions documented.

Further review showed the activities goal was under the problem of change in mobility related to the left hip fracture and the goal was to participate in a satisfying, diversional activity (recreational activities which promote self-esteem and personal fulfillment, through an emphasis on holistic care; providing physical, psychological, social, intellectual and spiritual/cultural support) of choice & interest and the intervention was to assess for physical limitations - focus on capabilities. There were no updates at the time of review.

3. Record review of Patient #6's H&P showed the patient was admitted to the swing bed on 12/01/11 for a fracture of the right hip. The medical chart also showed the patient had a past history of fractures of both hips.

Record review of the plan of care initiated 12/01/11 showed no documentation of an individualized plan of care based on the diagnosis and/or assessment and did not include personal goals and/or interventions regarding the right hip fracture or potential for falls.

4. Record review of Patient #7's H&P showed the patient was admitted to the swing bed on 12/22/11 for continuation of physical therapy after surgery for a small bowel obstruction.

Record review of the plan of care initiated 12/22/11 showed no documentation of an individualized plan of care based on the diagnosis and/or assessment and did not include personal goals and/or interventions regarding physical therapy. The activities goal was under the problem of change in mobility related to weakness and the goal was to participate in a satisfying, diversional activity of choice & interest and the intervention was to assess for physical limitations - focus on capabilities. No updating was documented.

5. Record review of Patient #18's H&P showed the patient was admitted to the facility on 10/27/11 for physical therapy, occupational therapy and IV antibiotics after toe amputation. The medical chart also showed the patient had diffuse peripheral arterial disease of the lower extremities as well as occlusive thrombosis of the right peroneal vein and possibly the distal aspect of the right political vein (the blood flow to her legs was severely compromised and a clot was in a right leg vein and possibly a clot was in the vein behind her right knee).

Record review of the plan of care initiated 10/27/11 showed no documentation of an individualized plan of care based on the diagnosis and/or assessment and did not include personal goals and/or interventions of the impaired circulation of the patient's legs. The activities goal was under the problem of change in mobility related to weakness and the goal was to participate in a satisfying, diversional activity of choice & interest and the intervention was to assess for physical limitations - focus on capabilities. No specifics of activities was individualized for this patient.

6. During an interview on 12/28/11 at 11:20 AM Staff J, Registered Nurse, stated that if she wanted information on the patient she would look at the cardex (a printed sheet of paper which gives all of the current information of a patient such as diet, mobility etc.