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Based on observation, interview and document review, the critical access hospital (CAH) failed to complete daily checks of the Zoll X series defibrillator monitors (used to create an electrical charge to stop an abnormal heart rhythm) for 3 of 3 defibrillator monitors reviewed equipment and supplies.

Findings include:

On 3/5/24 at 12:41 p.m., the Zoll X series defibrillator monitor on the medical surgical floor located on top of the crash cart had a testing strip exposed from the monitor indicating the monitor had only been checked 2/26/24 at 11:53 p.m., 2/27/24 at 11:33 p.m., 3/3/24 at 1:14 a.m., and 3/3/24 at 11:23 a.m. No additional testing strips were located.

On 3/6/24 at 9:56 a.m., registered nurse (RN)-I stated overnight nurses were responsible for charging and testing the Zoll X series defibrillator monitors. RN-I further stated a report would printed out after the test was completed and the checklist would then be signed off. RN-I stated the overnight charge nurse was responsible for ensuring all checks were done and the checklist was signed off.

On 3/6/24 at 11:59 a.m., chief nursing officer (CNO) stated nursing staff received Zoll X series defibrillator monitor training during orientation, and nursing staff were responsible for checking the Zoll X series defibrillator monitors daily. CNO further stated the defibrillator checks were included on the nightly checklist, and the charge nurse was responsible for ensuring all nightly tasks were completed. CNO stated she was not aware Zoll X series defibrillator monitors were not being checked nightly. CNO further stated she did not monitor the checklists daily because she thought the charge nurse was doing it. CNO stated her expectations were nursing staff should be checking the Zoll X series defibrillator monitors daily to make sure it is plugged in, charging, and daily testing is completed.

The Zoll X Series Defibrillator Monitor Advanced Operator's Guide undated directed to ensure the readiness and optimum working condition of the X Series Advanced unit, you should perform the following inspections and tests daily or at each shift change.

The facility policy Defibrillation review/revised date 7/18, lacked information about daily checks.


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Findings include:

On 3/5/24 at 1:59 p.m., in the emergency room (ER) daily checklists for ER rooms were reviewed. The checklists included testing the defibrillators in each room. The checklists revealed the following:

December 2023, no dates listed for (1, 2, 3, 4, 5, 7, 8, 10, 11, 13, 14, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 28, 29, 30). No defibrillator checks were completed.

January 2024, no dates listed for (1, 2, 3, 4, 6, 8, 9, 11, 13, 14, 16, 20, 21, 22, 23, 24, 26, 27, 29, 30, 31). No defibrillator checks were completed. In addition, on 1/12/24, the "Test Defib (30 joules)" was listed but not completed for ER 2.

February 2024, no dates listed for (1, 3, 4, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 28). No defibrillator checks were completed. In addition, on 2/2/24, the "Test Defib (30 joules)" was listed but not completed for ER 1 and on 2/5/24, no checks were completed for ER 1 and ER 2.

March 2024, no dated listed for (1, 2, 3). No defibrillator checks were completed.

On 3/5/24 at 1:59 p.m., nurse technician (NT)-A stated part of her duties were to complete the checklists for all the ER rooms daily, which would include testing the defibrillators in ER room 1 and ER room 2. NT-A verified the sheets were missing several dates for the past few months, and the defibrillator checks were not being completed daily.

On 3/5/24 at 2:05 p.m., emergency room manager (ERM)-H reviewed the checklists and verified the checks for the defibrillators were not being completed on a daily basis. ERM-H stated there were several days missing for the past few months. ERM-H stated when the NT was not working, another ER staff should have completed the checks.

Based on observation, interview, and document review, the critical access hospital (CAH) failed to maintain secure access to various departments throughout the hospital including the therapy department, emergency department (ED), laboratory, inpatient unit, surgical department and operating room, and identify visitors, patients, and the public. This had the potential to affect all patients and staff.

Findings include:

Basement

On 3/4/24 at 1:38 p.m., the outside public entrance to the therapy department was observed to be open and accessible to the public with a sign that indicated "doors open at 6:45 a.m." From the public access doors, patients, visitors, and the public had access to a set of double doors, labeled H030, with a sign that indicated "authorized personnel only." The doors had direct access into the basement and a stairwell to the 1st floor of the hospital. The maintenance manager (MM)-D stated the doors closed at 6:00 p.m. and a video camera was observed directly above the double doors. MM-D stated the video cameras were recording, but staff did not actively monitor the cameras on a 24 hour/7 days a week basis.

On 3/5/24 at approximately 8:30 a.m., the therapy receptionist (TR)-A stated the doors from the public entrance outside led directly to the double doors that indicated "authorized personnel only." TR-A acknowledged visitors, patients, or the public could walk through those doors and would have access to the hospital without every checking in at the registration desk with staff.

On 3/5/24 at approximately 9:00 a.m., the therapy manager (TM)-E stated the public entrance doors to the therapy department open at 6:45 a.m. and close at 5:30 p.m., and patients, visitors, or the public would have access through the double doors labeled "authorized personnel." When walking through the double doors and directly to the left, down a hallway, there was direct access to the maintenance department. The maintenance supply closet was propped open and inside were two saw blades, WD-40, glue, liquid ice machine cleaner, 18", 12", and 10" wrenches, various power drills, and various nails and screws. When exiting the maintenance supply closet and taking a direct left, then a right, and walking down the hallway, patients, visitors, and the public had access to a stairwell. TM-E stated a patient, visitor, or the public could access the 1st floor of the hospital, which included the inpatient units, the ED, and the laboratory and radiology department without staff supervisor or knowledge.

1st Floor Registration:

On 3/6/24 at 9:30 a.m., the main entrance receptionist (R)-C stated visitors would register at the reception desk. R-C would then call the unit and verify if the patient or unit was expecting a visitor. The visitor was then directed towards the wing of the hospital without staff accompaniment.

1st Floor Emergency Department:

On 3/4/24 at approximately 2:00 p.m., inside of the patient care area of the ED, were two double doors labeled 1019, and a sign indicating "authorized personal only." Through the double doors was an elevator which accessed the 2nd floor operating room (OR) and the basement, which included therapy services and maintenance.

On 3/5/24 at approximately 12:30 p.m., registered nurse (RN)-A stated patients within the ED would be able to walk through the double doors with the sign indicating "authorized personal only" without staff supervision or acknowledgement, and have access to the elevator to the 2nd floor which included the preoperative and post-operative unit and an unlocked operating suite with equipment and an unsupervised anesthesia machine. In addition, patients from the ED, using the same elevator, could access the basement, which included therapy and the maintenance department, without staff supervision or knowledge.

1st Floor Laboratory Department:

On 3/4/24 at approximately 2:30 p.m., the laboratory entrance, accessible to patients, visitors, and the public from the main and ED entrance, had a badge access reader for staff to scan themselves in and out of the laboratory department. However, the badge access reader had a green indication light, which indicated the door remained open without the need to scan a staff badge. Through the laboratory entrance was direct access to the laboratory draw rooms and inside was laboratory supplies that included needles, vacuum tubes, tourniquets, etc. Directly adjacent from the draw rooms, a door leading to the main laboratory was accessible. The main laboratory door did not include a badge access reader nor a video camera to monitor access.

On 3/5/24 at approximately 10:00 a.m., the laboratory and radiology receptionist (LRR)-D stated the laboratory doors remained open from 7:00 a.m. to 7:00 p.m.

On 3/5/24 at approximately 12:00 p.m., the laboratory manager (LM)-F stated the main laboratory entrance remained unlocked from 7:00 a.m. to 7:00 p.m., and acknowledged patients, visitors, and the general public could walk through the main laboratory doors, into the three main draw rooms and grab laboratory supplies which included needles, vacuum tubes, tourniquets, etc. and the main laboratory, which contained unlocked flammable chemicals without staff knowledge.

1st Floor Inpatient Unit:

On 3/4/24 at approximately 3:30 p.m., access from the inpatient floor to the obstetrical unit was divided by two double doors. A staff badge access read was not identified, however a video camera was recording and providing a live video stream to the nurse's station. However, there was no one actively monitoring the video monitors at the nurse's station.

On 3/4/24 at approximately 4:00 p.m., registered nurse (RN)-B stated patients or visitors from the inpatient unit who wanted to walk through to the obstetrical unit would be able to without staff supervision or knowledge. RN-B acknowledged the video monitors on the unit streamed live video to the nurse's station; however, staff were not always actively monitoring the video cameras.

On 3/6/24 at 10:01 a.m., the health unit coordinator (HUC)-H stated all inpatients wore a white, blue, or red wristband. If a visitor checked in at the registration desk, they are not given any type of identification. HUC-C also stated when she or staff checked in a visitor for the first time, they would confirm with the patient the visitor was authorized, and staff would escort them to the patient's room. However, after the visitor's first encounter, staff did not check to see if the visitor was authorized to access a patient's room and did not escort the visitor to the patient's room.

2nd Floor Surgical Department:

On 3/6/24 at 10:11 a.m., the surgical technician (ST)-J stated patients check in at the ER reception desk, and are given a white wristband. Visitors register in the ED, and visitors do not wear any type of identification or name badge once registered. ST-J stated visitors would go from the 1st floor ED to the 2nd floor surgical department unaccompanied by staff.

On 3/6/24 at 4:34 p.m., the chief executive officer (CEO) stated all entrances to the hospital remain locked except for the doors accessible to the public from the main entrance to therapy, the 1st floor main entrance and the ED, which all have video cameras. The CEO acknowledged all video cameras at the main entrances and registration desks were not always actively monitored by staff. The CEO stated the main entrance from the basement level therapy department directly accessible to the double doors labeled "authorized personnel only" would have the potential for a patient, visitor, or the public to walk through those doors and access the hospital without staff knowledge. In addition, the CEO stated patients within the ED would be able to walk through the double doors with a sign indicating "authorized personal" without staff knowledge, and could gain access to the basement and 2nd floor surgical department without staff supervision or knowledge. The CEO stated he was aware the laboratory department main doors remained unlocked during business hours. The CEO stated visitors did need to check in at the registration desks located at the main entrances of each department throughout the hospital. However, the CEO did state once a visitor has been to the hospital more than once and staff recognized them, there was no system to document authorized or unauthorized visitors. The CEO went on to state repeat visitors were not escorted by staff to their destination. The CEO stated because staff were not identifying visitors when they registered, there was a potential they or others could gain access to unauthorized areas in the hospital.

The facility policy Hospital Patient Visitor dated 1/1/24, directed Glacial Ridge Health System welcomes patient's choice of visitors including but not limited to a spouse, domestic partner, another facility member, or friends. The policy further directed Glacial Ridge Health System reserves the right to ask any visitor to leave in the event they are disruptive or disrespectful to the comfort of the patient they are visiting, as well as staff and other patients and visitors. In addition, the policy directed patients may decide to withdraw or deny permission for having visitors at any time throughout their stay, and anyone found in unauthorized locations may be re-directed and/or asked to leave.

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K0211, K0351, K0353, K0712, K0901 and K0914 for additional information.

Based on interview and document review, the critical access hospital (CAH) failed to report a change in the medical director to the State Agency (SA).

Findings include:

The facility Medical Staff Minutes dated 2/14/23 at 7:35 a.m., identified the approval of the election of physician (P)-A as Chief of Staff.

On 3/4/24 at 1:53 p.m., the chief executive officer (CEO) stated the medical director was appointed by the medical staff during the medical staff meeting in February, 2024.

On 3/4/24 at 2:18 p.m., health information management (HIM)-K provided the policy to inform the SA regarding changes to the medical director; however, was unable to speak on the process. HIM-K stated the person responsible was not in the office that day and she was unable to find any documentation that identified a notification to the SA had been completed.

The facility Bylaws of the Medical Staff undated, identified officers shall be elected at the annual meeting of the Medical Staff, which was usually held in February. Only active medical staff members may vote. Nominations would be made from the floor by members of the active staff only. Election shall be by closed ballot or voice vote at the annual meeting of the Medical Staff. All officers serve a two-year term from their election date or until a successor was elected. Officers shall take office on the first of the month following their election.

The facility policy Notification to Department of Health dated 9/26/05, identified the facility would notify the SA if there was a change in CEO or medical director.

Based on observation, interview, and document review, the critical access hospital (CAH) failed to properly clean 1 of 2 Nova Statstrip Glucose monitors reviewed for blood glucose monitoring of patients.

On 3/4/24 at 4:45 p.m., licensed practical nurse (LPN)-A was observed in P31's room. LPN-A applied gloves, removed alcohol wipes from a plastic bin, removed the Nova Statstrip Glucose monitor along with testing strips from a basket and placed on P31's bedside table. LPN-A obtained P31's blood glucose level, removed gloves and charted P31's blood sugar results. LPN-A placed the Nova Statstrip Glucose monitor back into the basket. LPN-A was not observed to clean the Nova Statstrip Glucose monitor prior to leaving P31's room.

On 3/5/24 at 11:00 a.m., LPN-A was observed to sanitize her hand and bring the blue basket with the Nova Statstrip Glucose monitor into P31's room. LPN-A set it on P31's bedside table. LPN-A applied gloves, pulled out and turned on the Nova Statstrip Glucose monitor. LPN-A completed a glucose check on P31. LPN-A placed the Nova Statstrip Glucose monitor back into blue basket and charted P31's blood glucose level. LPN-A sanitized her hands and left P31's room. LPN-A was not observed to clean the Nova Statstrip Glucose monitor before leaving P31's room. LPN-A entered the medication room, and placed blue basket onto counter. LPN-A took the Nova Statstrip Glucose monitor out of the basket, opened an alcohol wipe, wiped the front of the Nova Statstrip Glucose monitor, and placed the Nova Statstrip Glucose monitor back in the blue basket.

On 3/5/24 at 2:06 p.m., LPN-A stated the Nova Statstrip Glucose monitors needed to be cleaned before docking (charging) them. LPN-A stated the Nova Statstrip Glucose monitors needed to be cleaned with an alcohol wipe between patients. LPN-A stated the facility policy was the Nova Statstrip Glucose monitors should be cleaned with alcohol wipes prior to docking them.

On 3/5/24 at 2:10 p.m., registered nurse (RN)-F stated when nursing staff were finished using the Nova Statstrip Glucose monitors, the monitors needed to be cleaned with alcohol wipes between use. RN-F stated when all patients have had their blood glucose checked, nursing staff were to clean the Nova Statstrip Glucose monitors with Sani-wipes and wait until the monitor was dry to dock it. RN-F stated, "I have used an alcohol wipe also. I use the alcohol wipes more than the Sani-wipes."

On 3/6/24 at 11:18 a.m., laboratory manager (LM)-F stated nursing staff were to be cleaning the Nova Statstrip Glucose monitors with Dispatch hospital cleaner disinfectant towels with bleach between each patient use and before docking. LM-F further stated manufacture's recommendations for the Dispatch hospital cleaner directed the surface would need to stay visibly wet for one minute and left to air dry.

On 3/6/24 at 11:59 a.m., chief nursing officer (CNO) stated Nova Statstrip Glucose monitors should have been cleaned with Sani-cloths or an alcohol wipe. The CNO further stated Nova Statstrip Glucose monitors could be cleaned with bleach wipes, standard alcohol wipes, or a Sani-wipe. The CNO stated she was not aware of recommendations from the laboratory and what wipes should have been used. The CNO confirmed the recommended cleaning wipes from the laboratory were not in the medication room. The CNO stated her expectation were Nova Statstrip Glucose monitors were wiped down between each resident and before/after use. The CNO further stated nursing staff were expected to follow the cleaning guidelines for cleaning the Nova Statstrip Glucose monitors.

The Nova Biomedical manufacture's recommendations for customer information bulletin dated 12/4/12 directed all meter external surfaces should be cleaned and disinfected with a fresh Clorox Healthcare Bleach Germicidal Wipe.

The facility policy Nova Glucose Meter Cleaning dated 5/23/18 directed the Nova Blood Glucose meter should be cleaned and disinfected after each use using a bleach wipe such as Clorox Healthcare Germicidal Wipe.

Based on interview and document review, the critical access hospital (CAH) failed to ensure policies and procedures in the nursing, laboratory, anesthesia, facility wide, and emergency department were reviewed annually.

Findings include:

Review of nursing policies and procedures revealed the following:

NURSING
-Admission, Care of Antepartum/Intrapartum/Post-Partum Patient, and Discharge reviewed/revised 1/21.
-Admission of Patient to Hospital reviewed/revised 2/21.
-Malignant Hypothermia reviewed/revised 2/09.
-Health Care Directive/POLST Policy & Procedure reviewed/revised 6/20.
-Nova Glucose Meter Cleaning effective 5/23/18.
-Nova Statstrip POC Blood Glucose System reviewed/revised 7/18.
-Policy Governing the Administration of Medications reviewed/revised 2/13.
-Administration of Intramuscular Injection (Adult and Pediatric) reviewed/revised 1/20.

LABORATORY
-Novanet effective 5/30/18.

ANESTHESIA
-Do Not Resuscitate, or Allow Natural Death revised 9/22/15.

FACILITY WIDE
-Verbal and Telephone Orders reviewed/revised 1/10.

On 3/6/24 at 11:59 a.m., chief nursing officer (CNO) confirmed the above findings, and stated she was aware policies and procedures were not up to date. The CNO further stated the facility had been working on the policies and procedures, but not all of them had been updated. The CNO stated the facility's plan was to get the policies and procedures updated by the end of the year. The CNO stated expectations were for each department to review the policies and procedures, and update them as needed.

Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure nursing staff followed the policy for medication administration for 1 of 1 patients (P14) observed for medication administration.

Findings include:

On 3/4/24 at 4:15 p.m., registered nurse (RN)-B was observed to gather supplies to give P14's medications. RN-B reconstituted Pantoprazole (used to treat reflux disease) 40 milligrams (mg) with 10 millimeters (ml) of normal saline (NS) to achieve an intravenous (IV) push medication with the final strength of 40 mg. RN-B scrubbed the top of the Pantoprazole vial, injected 10 millimeters (ml) of NS, let it sit, then drew the 10 ml of medication from the vial and administered to R14.

On 3/5/24 at 10:14 a.m., RN-F was observed to gather supplies to give P14's medications. RN-F reconstituted Pantoprazole 40 mg with 10 ml of NS to achieve an IV push medication with the final strength of 40 mg. RN-B scrubbed the top of the Pantoprazole vial, injected 10 ml of NS, let it sit, then drew the 10 ml of medication from the vial and administered to R14.

On 3/5/24 at 2:10 p.m., RN-F stated it was the first time she had reconstituted Pantoprazole since she started working at the facility. RN-F further stated nurses reconstituted many medications.

On 3/6/24 at 11:59 a.m., chief nursing officer (CNO) confirmed the above findings and stated reconstitute of medications on the medical surgical floor was usually only done for IV push medications. The CNO stated pharmacy was responsible for reconstituting medications during pharmacy hours, and nursing staff should only reconstitute medications when the pharmacy staff were not in the office (after hours), on weekends, or in an emergency.

On 3/6/24 at 1:00 p.m., the pharmacist (P)-a confirmed the above findings, and stated nursing staff would reconstitute some powder medications. P-A stated most of the reconstituted medications were antibiotics, but did include some additional medications. P-A stated medications should be reconstituted in the pharmacy during normal pharmacy hours, and the reason nursing staff were reconstituting medication during pharmacy hours on the medical surgical floor was for convenience. P-A stated all reconstitution of medications should be completed by the pharmacy and the only time nursing staff should be reconstituting medications was if pharmacy was not available (after hours) or in an emergency.

The facility policy Pharmacy Policies and Procedures reviewed/revised 2/24, directed the preparation of admixtures of medications is the responsibility of the pharmacist or the licensed nurse (when the pharmacist is not available). Admixtures are to be prepared only in a dedicated area.

Based on interview and document review, the critical access hospital (CAH) failed to collaborate and communicate with the Organ Procurement Organization (OPO) to ensure every patient's death was being reviewed.

Findings include:

Review of the facility's Death Summary Report date 3/1/23 to 11/30/23, the facility had 12 deaths.

Review of the facility's 2023 Tissue & Eye Donation Activity Report dated 12/31/23, the facility contacted the OPO for 15 facility deaths.

On 3/5/24 at 3:33 p.m., chief nursing officer (CNO) confirmed the above findings and stated she received a quarterly and yearly report from the OPO. The CNO stated she reviewed the report and nothing else was done with the report.

On 3/5/24 at 4:22 p.m., the CNO stated she looked through the report for the compliance rate and the timeliness. The CNO stated indicated she did not match the report with reported facility deaths. The CNO further stated she had not had any communication with the OPO regarding the report. The CNO stated the report was sent to her, the acute care manager and the emergency department manager. The CNO further stated there was no additional communication with other departments regarding the report. The CNO confirmed the lack of communication between the facility and the OPO.

A policy on OPO was requested, but not provided.

Based on interview and document review, the critical access hospital (CAH) failed to develop an abuse policy and procedure for its Swing Bed Unit to include immediate (not to exceed 2 hours) notification to the State Agency (SA) for all alleged violations involving abuse, neglect, exploitation or mistreatment. This deficient practice had the potential to affect all current Swing Bed patients and all future Swing Bed patients receiving services by the CAH.

Findings include:

The facility policy Reporting Abuse to State Agencies and Other Entities/ Individuals reviewed 1/24, directed all alleged/suspected violations and all substantiated incidents of abuse would be promptly reported to appropriate SA, other entities or individuals as required by law. The policy further directed notices would be provided to the above agencies/individuals within 24 hours after the occurrence of the incident, or when the facility learned of the abuse.

On 3/6/24 at 2:35 p.m., the director of nursing (DON) stated she expected staff to contact her or the chief executive officer (CEO) immediately when an allegation of abuse was reported. The DON confirmed the facility policy identified the facility had 24 hours to report an allegation of abuse to the SA. In addition, DON stated she was not aware a facility was expected to report all allegations of abuse immediately.

On 3/6/24 at 3:00 p.m., the CEO stated he believed the facility had 24 hours to report allegations of abuse, and was not aware the facility was expected to report immediately.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure comprehensive patient-centered care plans with goals were developed for 5 of 5 patients (P1, P28, P29, P30, and P31) reviewed on the Swing Bed (SB) Unit.

Findings include:

P1's electronic medical record (EMR) revealed an admission date of 3/1/24, with diagnoses which included back and hip pain, and lumbago with sciatica.

P1's care plan revised 3/4/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, Occupational Therapy (OT) general evaluation and Physical Therapy (PT) general evaluation. The care plan lacked any measurable goals to ensure patient-centered care was provided.

P28's EMR revealed an admission date of 1/5/24, with diagnoses which included pneumonia and atrial fibrillation.

P28's care plan revised 1/17/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, OT general evaluation and PT general evaluation. The care plan lacked any measurable goals to ensure patient-centered care was provided.

P29's EMR revealed an admission date of 1/18/24, with diagnoses which included right hip repair and displaced fracture of right femur.

P29's care plan revised 1/31/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, OT general evaluation and PT general evaluation. The care plan lacked any measurable goals to ensure patient-centered care was provided.

P30's EMR revealed an admission date of 2/21/24, with diagnoses which included chronic obstructive lung disorder (COPD) and alcohol dependence.

P30's care plan revised 3/4/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, OT general evaluation and PT general evaluation. The care plan lacked any measurable goals to ensure patient-centered care was provided.

P31's EMR revealed an admission date of 3/1/24, with diagnoses which included enterococcal bacteremia and cellulitis of the right lower limb.

P31's care plan revised 3/4/24, had a column listed as standard of care and had several items identified under the column which included: admission assessment, patient belongings, activity as ordered, OT general evaluation, PT general evaluation and infection risk. The care plan lacked any measurable goals to ensure patient-centered care was provided.

On 3/6/24 at 9:15 a.m., registered nurse (RN)-D confirmed the care plans for P1, P28, P29, P30 and P31 were not patient centered and lacked goals. RN-D stated the facility was aware the care plans "needed work."

On 3/6/24 at 12:45 p.m., the director of nursing (DON) confirmed the SB patient care plans were not patient centered and lacked goals.

The facility policy Swing Bed Comprehensive Care Plan Policy and Procedure reviewed 1/24, directed an initial care plan would be developed for each swing bed patient that would include measurable objectives and timetables to meet a swing bed patient's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment.