HospitalInspections.org

Based on medical record review, review of policy and procedure and staff interview, the Critical Access Hospital (CAH) failed to ensure a comprehensive assessment, and a discharge summary was completed on 5 (patient 32, 33, 34, 35, 36) of 5 swing bed records. This failed practice has to the potential to affect all swing bed patients of the CAH. The number of swing bed patients at the CAH for fiscal year 2025 was 117.

Findings are:

- Review of Patient 32's medical record (7/31/25 at 8:20AM) revealed a swing bed admission of 1/15/25-1/23/25 for altered mental status and weakness. Review of the entire medical record revealed a comprehensive assessment (1/22/25) that lacked documentation of cognitive patterns, mood and behavior patterns, activity pursuits and medications. Review of the discharge summary (1/23/25) lacked documentation of the recapitulation of the patients stay that includes patient diagnoses, course of illness/treatment or therapy, pertinent lab, and radiology and consultation reports. The discharge summary also lacked evidence of a final summary of the patients status and the reconciliation of pre-discharge medications with post discharge medications.

- Review of Patient 33's medical record (7/31/25 at 9:29AM) revealed a swing bed admission of 2/28/25-3/24/25 for a subarachnoid hemorrhage (bleeding around the brain). Review of the entire medical record revealed a comprehensive assessment (2/28/25) that lacked documentation of mood and behavior patterns, dental and nutritional status, activity pursuits and medications. Review of the discharge summary (3/24/25) lacked documentation of the recapitulation of the patients stay that includes diagnoses, course of illness/treatment or therapy, pertinent lab, radiology and consult reports. The discharge summary also lacked evidence of a final summary of the patients status and the reconciliation of pre-discharge medications with post discharge medications.

- Review of Patient 34's medical record (7/31/25 at 10:00AM) revealed a swing bed admission of 3/6/25-3/27/25 for septic arthritis with a partial knee revision (an infection of a joint requiring a procedure to replace part of an artificial joint). Review of the entire medical record revealed a comprehensive assessment (3/6/25) that lacked documentation of mood and behavior patterns, activity pursuits and medications. Review of the discharge summary (3/27/25) lacked a recapitulation of the patients stay that includes diagnoses, course of illness/treatment or therapy, pertinent lab, radiology and consult reports. The discharge summary also lacked evidence of a final summary of the patients status and the reconciliation of pre-discharge medications with post discharge medications.

- Review of Patient 35's medical record (7/31/25 at 10:28AM) revealed a swing bed admission of 4/10/25-5/8/25 for a cerebral vascular accident (CVA or stroke is a blood clot in the brain that causes neurological deficiencies). Review of the entire medical record revealed a comprehensive assessment (4/11/25) that lacked documentation of mood and behavior patterns, activity pursuits and medications. Review of the discharge summary (5/8/25) lacked the recapitulation of the patients stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consult reports. The discharge summary also lacked evidence of a final summary of the patients status and the reconciliation of pre-discharge medications with post discharge medications.

- Review of Patient 36's medical record (7/31/25 at 10:48AM) revealed a swing bed admission of 5/5/25-5/12/25 for cellulitis (infection in the skin). Review of the entire medical record revealed a comprehensive assessment (5/5/25) that lacked documentation of mood and behavior patterns, activity pursuits and medications. Review of the discharge summary (5/12/25) lacked the recapitulation of the patients stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consult reports. The discharge summary also lacked evidence of a final summary of the patients status and reconciliation of pre-discharge medications with post discharge medications.

- Review of the facility policy Comprehensive Assessment Form (CAF) Swing Bed: Completion of Form (review date unknown), revealed the comprehensive assessment will describe the patient's capacity to perform daily life functions and significant impairments describing the patient's capacity to perform daily life functions and significant impairments in functional and mental ability.

- Review of the facility policy Final Summary of Patient's Swing Bed Stay (review date unknown), revealed the final summary provides the following information: A recapitulation of the patient's stay, final summary of patient's previous and current status, post discharge plan which outlines services, follow up, durable medical equipment, referrals to support agencies, how the patient or family will access services, outpatient therapies, and continued education needs.

- Interview (8/31/25 at 11:15AM) with RN-A confirmed the comprehensive assessments and discharge summaries for the above medical records lacked required information.