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Based on a record review and staff interview, the Critical Access Hospital failed to ensure documentation of a History and Physical examination which included a descriptive neurological examination indicating what tests were performed to assess neurological functioning for 5 (#8, #9, #10, #11, #12) of 20 sampled patients. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.
Findings:

Review of the hospital's policy PC-403 titled, "History and Physical Assessment", revealed in part: A complete admission history and physical examination, to include an examination of cranial nerves, shall be recorded within 24 hours of admission.

Review of Patient #8's history and physical failed to reveal a detailed cranial nerves assessment.

Review of Patient #9's history and physical failed to reveal a detailed cranial nerves assessment.

Review of Patient #10's history and physical failed to reveal a detailed cranial nerves assessment.

Review of Patient #11's history and physical failed to reveal a detailed cranial nerves assessment.

Review of Patient #12's history and physical failed to reveal a detailed cranial nerves assessment.

In an interview on 07/27/2021 at 3:15 p.m., S6LPN confirmed Patients #8, #9, #10, #11 and #12's history and physical did not contain a detailed cranial nerves assessment but merely listed cranial nerves 2-12 intact.

Based on observation and interview, the Critical Access Hospital failed to ensure the health and safety of patients by failing to ensure a call system was available in the Emergency Department's waiting area restrooms and failing to ensure staff access to patient's locked inside the restrooms.
Findings:

An observation on 07/26/2021 at 1:35 p.m. of the Emergency Department's male and female waiting area restrooms failed to reveal a nurse call bell. Further review revealed the doors could be locked from the inside.

In an interview on 07/26/2021 at 1:40 p.m., Emergency Department Director S7RN verified the bathrooms failed to contain a call system and the doors could be locked from the inside. He also, verified he was not aware where the key for the bathrooms was located.

Based on record review and interview, the Critical Access Hospital failed to ensure a patient's history and physical was promptly completed for 1 (#8) out of a total sample of 20 patients.
Findings:

Review of the hospital's Rules and Regulations revealed in part: (8). A complete history and physical examination shall in all cases be recorded within twenty-four (24) hours after admission of the patient.

Review of Patient #8's medical record revealed an admit date of 07/17/2021 with a history and physical completed on 07/19/2021.

In an interview on 07/27/2021 at 3:15 p.m., S6LPN confirmed Patient #8's history and physical was not completed within 24 hours.

Based on record review and interview, the CAH failed to ensure the current patients classified as swing bed patients were informed of their SNF patients' rights for 4 of 4 (#2, #3, #4, #5) sampled swing bed patients reviewed from a total patient sample of 20.

Findings:

Review of the patient rights supplied to the current swing bed patients in the CAH revealed the following SNF patient rights were not include in the information provided to the patients:

The resident has the right to be informed of, and participate in, his or her treatment, the right to be informed, in advance, of changes to the plan of care.

The resident has the right to choose his or her attending physician.

The resident has the right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

The resident has the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time;

The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;

The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: Access to stationery, postage, and writing implements at the residents own expense.

The resident has the right to be informed, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may and may not be charged.

The resident has the right to personal privacy and confidentiality of his or her personal and medical records.

An interview was conducted with S5UR on 07/27/2021 at 3:45 p.m. S5UR confirmed the patient rights for the swing bed patients did not include specific patient rights for swing bed patients.