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Based on interview and record review, the facility failed to adopt Medical Staff Bylaws that give only the Governing Body the authority to grant medical staff privileges. This deficient practice had the potential for all patients admitted to the facility to receive substandard care. The facility census was 14.

Findings included:

Record review of the facility's Medical Staff Bylaws, dated May, 2016, in Article VIII, Emergency and Temporary Privileges, #3 showed, the Hospital's Administrator, after consultation with the Chief of Staff, shall have authority to grant temporary privileges to a physician, dentist or podiatrist who are not members of the Staff.

During an interview on 03/01/17 at 3:15 PM, Staff P, Chief Executive Officer (CEO), stated that she had just recently granted two physicians temporary privileges because of an emergency billing issue when the Board of Directors could not be convened.

Based on observation and interview the facility failed to ensure foods were dated when opened and removed from patient consumption after expiration date. These deficient practices placed all patients at risk for unsanitary food service and cross contamination of food. The facility census was 14.

Findings included:

1. Although requested, the facility failed to provide a policy on how long opened packages of food could be stored before it should be wasted (thrown out).

2. Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2013 Food Code, Chapter 3-302.12, "Food Storage" showed direction for facility dietary staff to label food with the dated opened.

3. Observation on 03/01/17 at 1:35 PM, in the kitchen dry storage room, showed the following opened food containers that were not labeled with the date opened or removed from storage when expired:
- An opened bag of instant mashed potatoes;
- An opened container of peanuts;
- An opened bag of marshmallows that was opened on 08/02/16 and 11 unopened bags. All of these were dated with a manufacturers expiration date of 02/27/17.

During an interview on 03/01/17 at 2:00 PM, Staff N, Dietary Supervisor, stated that all opened items should be marked with the date the food was opened. Staff N stated that she was not sure how long the food could remain in storage after opened and, "the time is different for different products." She also stated that expired items should be thrown away but wasn't sure if there was a facility policy related to this.

Based on interview, record review, and policy review, the facility failed to develop a comprehensive assessment of activity interest and abilities with goals for two (#23 and #24) of three discharged Swing Bed patients (a program with a change in reimbursement status where the patient goes from acute care services and reimbursement status to receiving skilled nursing services and reimbursement) reviewed. This deficient practice had the potential to negatively impact the quality of life for the Swing Bed patient during their admission to the facility. The facility census was 14.

Findings included:

1. Record review of the facility's undated Policy and Procedure titled, "Documentation of Activities," showed that a patient in the Swing Bed Program should have documentation that included:
- Individual patient assessment with weekly progress notes;
- Activity plan included as part of the Interdisciplinary Plan of Care;
- Activities attendance records;
- Calendar of activities;
- File of community resources; and
- List of diabetic patients and others on special diets

During an interview on 03/01/17 at 9:10 AM, Staff L, Swing Bed Activities Coordinator, stated that all patients received an activities assessment within 48 hours of admission. If she was unable to complete the assessment, then Staff O, Social Work Director, would complete the necessary evaluation and documentation.

2. Record review of Patient #23's medical record showed that he was a 78 year old male who was admitted to the acute inpatient unit on 01/23/17 and was transferred to a Swing Bed status on 01/27/17 with a diagnosis of acute delirium (temporary confusion and a change in the alertness and awareness of surroundings). The patient was discharged from the Swing Bed program on 01/31/17. Upon review of the record, there was no Swing Bed Recreation (Activity) Therapy Assessment.

3. Record review of Patient #24's medical record showed that he was a 75 year old male who was admitted to the Swing Bed program on 02/15/17 with a diagnosis of Status Post Myocardial Infarction (commonly known as a heart attack, occurs when blood flow stops to a part of the heart causing damage to the heart muscle). The patient was discharged at his own request from the facility on 02/17/17. Upon review of the record, there was no Swing Bed Recreation (Activity) Therapy Assessment.

During an interview on 03/01/17 at 1:15 PM, Staff O, Social Work Director, confirmed that she was responsible for the management of the Swing Bed Program. Her expectation was that all patients would receive a Swing Bed Recreation (Activity) Therapy Assessment within 48 hours of their admission. Staff L was responsible for completing the assessment, but if she was unable to complete it for any reason, she was to contact Staff O who was also certified to be able to do the evaluation and document the assessment. Staff O stated that there was no excuse for a Swing Bed Recreation (Activity) Therapy Assessment not to be completed.