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Based on review of medical records (MR), facility policies and interviews it was determined the nursing staff failed to:

1. Perform wound care as ordered and ensure complete wound care orders were obtained.

2. Measure wounds and document wound assessments per policy.

3. Follow physician orders for insulin administration and performing pattern blood glucose testing as ordered.

This affected 4 of 9 inpatient records reviewed and did affect MR # 9, # 11, # 12, # 14 and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy
Wound Assessment and Reassessment
Reference: NS0285
Effective: 3/2015

Wound Assessment and Reassessment

Policy:
"It is the policy of this hospital that each patient admitted shall receive a complete head to toe assessment by a qualified individual so that plan of care can be developed...

Upon completion of the initial admission assessment, an individualized prioritized plan of care will be developed...

Wound measurements:
Length
Width
Depth

Wound bed tissue:
Presence and amount of necrotic tissue expressed in percentages

Presence of exudate:
Amount (scant, moderate, large)
Color: serous, serosanguinous, sanguineous
Consistency: thick, milky, purulent...

Skin around the wound:
Palpate the skin around the finger tips (within four (4) centimeters (cm) of the wound's edge.)...

Note:
Wounds should be assessed after the wound has been cleansed..."

"Biocclusive Dressing (DuoDERM) package insert...
Directions for Use:
1. Wound Site Preparation and Cleansing
Before using the dressing, clean the wound with an appropriate cleaning agent or normal saline and dry the surrounding skin.
3. Dressing change and removal:
b. The dressing should be changed when: clinically indicated, when strike-through occurs, or up to a maximum of seven days. The wound should be cleansed at appropriate intervals..."

1. MR # 9 was admitted to the facility on 2/2/18 with a diagnosis including Fractured Femur.

Review of the 2/2/18 Physician Verbal Orders for admission to the facility included, "Wound Care per Nursing".

Review of the 2/2/18 to 2/16/18 daily AM and PM nursing notes revealed no documentation of the wound care provided, complete description of the wound/ peri wound and measurements.

The surveyor asked Employee Identifier (EI) # 2, Inpatient Care Services Director, what were the actual wound care orders, the response was, "There were none."

In an interview conducted on 4/4/18 at 10:00 AM with EI # 2, confirmed the staff failed to obtain complete wound orders, and document care and description per policy.



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2. MR # 11 was admitted to the facility on 1/16/18 with diagnoses including Rehabilitation Secondary to Acute Systolic Congestive Heart Failure (CHF) Exacerbation and Hypertension (HTN)

Review of the Pharmacy Order # 1123046 dated 1/16/18 revealed an order for Silver Sulfadiazine 1% Cream daily to the left foot.

Review of the Transitional Care Shift Assessment New on 1/16/18 revealed the following nursing documentation: "Round spot on left heel where a blister has busted." Left heel was further documented in the nursing documentation as a stage 2- Partial thickness skin loss.

Further review revealed the nurse failed to perform wound care as ordered by the physician, document measurements of the wound, document the appearance of the wound bed tissue, or document appearance of the wound edges and surrounding skin on the following dates:
Transitional Care Shift Assessment New dated 1/16/18 at 7:37 PM,
Transitional Care Shift Assessment New dated 1/19/18 at 9:10 AM,
Transitional Care Sift Assessment New dated 1/19/18 at 9:45 PM,
Transitional Care Shift Assessment New dated 1/20/18 at 7:50 AM,
Transitional Care Shift Assessment New dated 1/20/18 at 8: 30 PM,
Transitional Care Shift Assessment New dated 1/21/18 at 7:50 AM,
Transitional Care Shift Assessment New dated 1/22/18 at 7:34 AM

In an interview conducted on 4/5/18 at 10:56 AM with EI # 2, confirmed the above findings.

3. MR # 12 was admitted to the facility on 3/22/18 with diagnoses of Status Post Left Hip Fracture with Pinning, Diabetes Mellitus and Hypertension.

Review of the 3/22/18, 4:29 PM Physician's Order for the pattern blood glucose (BS) levels for 7:00 AM, 11:00 AM, 4:00 PM and 11:00 PM and revealed the following sliding scale orders
For BS below 70, give 0 Units. Call MD if no standing order
From 70 to 150 give 0 Units (U)
BS 151 to 200 give 3 U
BS 201 to 250 give 5 U
BS 251 to 300 give 7 U
BS 351 to 400 give 11 U
For BS above 400, give 0 U. Call MD

Review of the MR revealed the following documentation for the treatments of BS:

3/22/18 at 9:15 PM, BS was 174 and at 9:00 PM, missed dose entry was entered with no documentation of the reason for the missed dose. 3 U should have been given per physician's order.

3/25/18 at 4:11 PM, BS was 168 and at 4:00 PM, documentation showed a missed dose entry was done with comment of "no coverage needed". 3 U should have been given per physician's order.

3/25/18 at 9:45 PM, BS was 208 and at 9:00 PM, missed dose entry was entered with no documentation of the reason for the missed dose. 5 U should have been given per physician's order.

3/26/18 at 9:14 PM, BS was 193 and at 9:00 PM, missed dose entry was entered with no documentation of the reason for the missed dose. 3 U should have been given per physician's order.

3/28/18 at 4:35 PM, BS was 219 and at 4:00 PM, missed dose entry was entered with no documentation of the reason for the missed dose. 5 U should have been given per physician's order.

3/28/18 at 9:07 PM, BS was 233 and at 9:00 PM, missed dose entry was entered with no documentation of the reason for the missed dose. 5 U should have been given per physician's order.

3/29/18 at 5:17 AM, BS was 156 and at 7:00 AM, missed dose entry was entered with no documentation of the reason for the missed dose. 3 U should have been given per physician's order.

3/29/18 at 11:07 AM, BS was 176 and at 11:00 AM, missed dose entry was entered with no documentation of the reason for the missed dose. 3 U should have been given per physician's order.

3/29/18 at 4:33 PM, BS was 187 and at 4:00 PM, documentation showed a missed dose entry was done with comment of "no coverage needed". 3 U should have been given per physician's order.

In an interview conducted on 4/5/18 at 10:47 AM with EI # 2, confirmed the above findings.



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Further review of MR # 12 revealed physician history and physical documentation dated 3/28/18 that reported MR # 12 had a wound vac (vacuum assisted wound closure) to a left hip surgical incision site prior to transfer to the transitional care unit. The physician documented in the skin assessment the patient complained of pain in the buttock areas due to bed sores.

Review of physician orders dated 3/22/18 included orders for a dry 4 x 4 (4 inch by 4 inch gauze) every other day and as needed to left surgical hip site.

The medical record contained wound photographs with description dated 3/22/18 at 10:00 PM which revealed one right and one left buttock stage 2 pressure ulcer and two posterior right hip pressure ulcers, stage 2 and length and width measurements documented.

There was no wound depths, no documentation of the absence/presence of wound drainage and no description of the surrounding skin integument documented for the stage 2 pressure ulcers. There was no wound site assessment documented for the left hip surgical wound.

Record review revealed an order dated 3/23/18 at 10:17 AM for duoderm to buttocks as needed. There was no documentation what solution the wounds were to be cleaned with and no frequency the duoderm dressing was to be applied.

Further review of the medical record failed to contain documentation staff performed a dry 4x4 dressing to the left surgical hip wound on 3/24/18, 3/26/18, 3/28/18, 3/30/18 and 4/2/18. There was no documentation when the duoderm to the buttocks was applied.

Review of the nurse documentation dated 4/1/18 at 9:44 AM revealed a silvadene dressing was on wound # 2. There was no documentation which wound was wound # 2 and no physician's order for a silvadene dressing.

During an interview on 4/5/18 at 9:59 AM, EI # 2, Inpatient Care Services Director confirmed the findings above.

4. MR # 14 was admitted to the transitional care unit on 12/7/17 with diagnoses including Status Post Cerebrovascular Accident and Diabetes Mellitus Type 2.

Medical record review revealed orders dated 12/8/17 for pattern blood glucose to be obtained at 7:00 AM, 11:00 AM, 4:00 PM and 9:00 PM daily for sliding scale insulin administration four times a day.

Medical review revealed pattern blood sugars were obtained on 12/13/17 at 4:57 AM, which was greater than 2 hours too early, on 12/11/17 at 5:35 AM, 85 minutes early and on 12/12/17 at 5:40 AM, which was 80 minutes early.

In an interview on 4/5/18 at 8:56 AM, EI # 2, reported the morning insulin dose was determined by the pattern blood glucose levels.

On 4/5/18 at 9:50 AM, EI # 8, the Laboratory Director verified the lab staff was collecting the 7:00 AM pattern glucose levels when 5:00 AM morning labs were obtained.

Based on observation and interview, the facility failed to assure all medications and biologicals available for patient use in the Pharmacy Department were not expired. This had the potential to negatively affect all patients.

Findings include:

1. A tour was conducted on 4/3/18 at 10:00 AM in the Pharmacy Department. The following expired medications were found:

10 bags of D5W (5 percent Dextrose in water) 500 cc (cubic centimeter) bags in a bin which expired 3/18.
1 vial of Garamycin in 0.9 % (percent) NaCl (Sodium Chloride) in the vaccine refrigerator which expired 3/18.
4 bags of IV Garamycin in 100 cc NS (Normal Saline) with discharged patients names on them, which expired 3/18.

An interview conducted on 4/3/18 at 10:30 AM with Employee Identifier (EI) # 12, Pharmacist, who verified the above and stated the expired medications should have been disposed of by pharmacy technicians.



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During a tour of the Rehabilitation Unit on 4/3/18 at 1:20 PM, the surveyors observed four (4) of 4 bottles of Hydrogen Peroxide with expiration dates of 2014.

In an interview on 4/3/18 at 1:25 PM, EI # 4, Director of Rehabilition reported wound care was performed in the Rehabilition Unit on occasions and EI # 4 confirmed the supplies were expired.

Based on review of facility policies, observations and staff interviews, the hospital failed to ensure:

1. All food items not stored in the original container were clearly labeled to assure items were identifiable and not out of date.
2. Frozen food items were kept frozen per manufacturer's directions.
3. Sanitized items were stored clean.

This had the potential to affect all patients served by the dietary department.

Findings include:

Policy: Cleaning Procedure Manual, Dietary
Reference: D10015
Reviewed: 1/18

..."Freezer Daily:... Straighten boxes putting like items together.
Make sure all items are dated with an "in" and "out" date.

Walk in Freezer Daily:...Check to be sure all items are labeled and dated....

Dishwashing...Do not carry dishes so that they come in contact with your clothing. This can cause cross contamination. Use clean carts to transport."
*****

1. A tour of the dietary department was conducted on 4/3/18 at 11:05 AM, with Employee Identifier (EI) # 9, Dietary Manager. During observations of frozen and refrigerated food storage areas the following was observed by survey staff:

1. Two gallon clear plastic Zip-lock bag with no date or label identified as "green beans" by EI # 9 with a hole in 1 bag and both were freezer burned.
2. One gallon clear plastic bag with no date or label identified as "mixed vegetables" by EI # 9 that were freezer burned.
3. Three gallon clear plastic Zip-lock bag with no date or label identified as "chicken breasts" by EI # 9, 2 of the bags were freezer burned.
4. 2 Gallon sized plastic Mayonnaise jars with frozen liquid inside and identified as "juice that we mix up and freeze for later use" by EI # 9.
5. 10 loaves of bread, with use by date of 2/23/18, with large pieces of ice sitting on them.
6. The shelf in the back left corner of the freezer contained boxes of meat and loaves of bread which were covered with large pieces of ice, each approximately 4 centimeters in diameter.

Survey staff continued the tour of the dietary department and identified the ice cream freezer which had 6 large Styrofoam cups, labeled "Strawberry Ensure" with no use by dates on them. Also in the ice cream freezer were 2 large Styrofoam cups, labeled "Chocolate Ensure" with use by date of 11/18. EI # 9 stated items were supposed to have use by dates of no longer than 3 months.

On 4/3/18 at 1:12 PM, the surveyor observed the sanitization process for dishes, pots, pans, trays and silverware. After the items went through the dishwasher, EI # 11, Dietary Aide/Cook, was observed putting up the clean items. EI # 11 failed to use gloves when putting up the clean dishes, pots, pans, trays and silverware.

An interview was conducted on 4/4/18 at 8:10 AM with EI # 9, who confirmed the above findings and stated all food items placed in other containers should be labeled and dated and identified and staff are required to wear gloves when putting up sanitized items.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on observation of the Emergency Room (ER) Department and staff interviews, it was determined the facility failed to ensure the Emergency Call Light System in the ER was inspected annually and maintained to ensure an acceptable level of safety and quality. This had the potential to negatively affect all patients served by the facilities ER Department.

Findings include:

1. A tour was on conducted on 4/3/18 at 9:45 am with Employee Identifier (EI) # 14, Emergency Room (ER) Manager.

The ER had 2 private treatment rooms with a door to close for privacy; a Medical Treatment room, on the left side of the nurses' station, with 3 bays separated by curtains and a set of double doors at the entrance; and a Trauma room on the right side of the nurses' station, with 2 bays separated by curtains and a closed double door at the entrance. The patients' beds were not visible from the nurses' station.

The ER had a total of 7 bays. There were no operational call lights at any of the bedsides in the 7 bays.

The surveyor noted a call light system was on the wall of each of the rooms, but no pull cords were attached. EI # 14 stated the call light system in the ER had not worked in over 5 years. There were no biomedical stickers on the call light system.

An interview was conducted 4/3/18 at 2:00 PM with EI # 14, who confirmed the facility failed to provide the patients with a method of alerting staff for needs while being treated in the ER due to the inoperable Call System.

Based on facility policy and procedure, observations and interviews, it was determined the facility staff failed to follow infection control procedures and:

1) Wear gloves during equipment cleaning.

2) Perform and document cleaning of all equipment in the rehabilitation department.

3) Perform hand hygiene when appropriate.

Findings include:

Subject: Hand Hygiene
Reference #: IC4002
Reviewed: 2/18

"Goal:
To reduce the risk of health care associated infections...

Glove use:
b. Gloves should be changed, and hand hygiene performed after using gloves for contaminated activities.
c. Gloves should be changes when caring for a single patient when moving from one procedure to another...


Subject: Standard/ Universal Precautions
Reference #: IC 0025
Reviewed: 2/18

"Purpose:

To prevent transmission of disease that can be required by contact with blood, body fluids, non-intact skin...and mucous membranes. These measures are to be used when providing care to all individuals, whether or not they appear infectious or symptomatic. Standard/universal precautions are the basic level of infection precautions.

Hand Hygiene is a major component of standard/universal precautions and is one of the most effective methods to prevent transmission of pathogens associated with health care....

PPE (personal protective equipment) includes...gloves, gowns...used to create barriers that protect skin, clothing...The type of protective barrier (s) should be appropriate for the procedure being preformed and the type of exposure anticipated...

Subject: Infection Control Procedures:
Reference: # PT0260
Department: Physical Therapy
Reviewed: 2/18

Equipment Cleaning Procedures:

A. Hydrocollator...to be done monthly or more often as necessary.
B. Hot Pack Covers...To be done quarterly or more often as necessary.
C. Paraffin Bath: To be done every six month (minimum)...
D. Exercise Mat/Treatment Plinth...To be done daily.
E. Exercise/Traction equipment...To be cleaned after each patient use and monthly.
F. Treatment Machines...To be done monthly...

1. During a tour of the out-patient rehabilitation unit on 4/3/18 at 1:15 PM, Employee Identifier (EI) # 5, Physical Therapy Technician was cleaning equipment that included an exercise ball and treatment matt. EI # 5 was not wearing gloves.

Review of the rehabilitation unit cleaning log documentation for March 2017 to March 2018 revealed the staff failed to perform and document the following:

March 2017: Daily: Hydrocollator, Paraffin temperature and freezer temperatures monitored and exercise mat cleaned on 3/15/17, 3/16/17 and 3/18/17:
Monthly: Treatment machines, Hydrocollator, biohazard cans and carts cleaned.
Quarterly: Hot pack covers washed.

April 2017: Monthly: Biohazard cans and carts cleaned.

May 2017: Monthly: Biohazard cans cleaned.

June 2017: Monthly: Biohazard cans cleaned;
Quarterly: Hot pack covers washed.

July 2017: Monthly: Treatment machines, Hydrocollator, biohazard cans and carts cleaned.

August 2017: Monthly: Biohazard cans cleaned.

September 2017: Monthly: Treatment machines and carts cleaned.
Quarterly: Hot pack covers washed.

October 2017: Monthly: Treatment machines, biohazard cans and carts cleaned.

November 2017: Monthly: Biohazard cans cleaned.

December 2017: Monthly: Biohazard cans cleaned.

March 2018: Monthly: Treatment machines, Hydrocollator, biohazard cans and carts cleaned.
Quarterly: Hot pack covers washed.

There was no documentation paraffin was cleaned from March 2017 to March 2018 and no documentation the paraffin was not used.

In an interview conducted on 4/3/18 at 2:40 PM, EI # 4, Rehabilition Department Director confirmed staff failed to wear gloves during equipment cleaning and perform and document all equipment cleaning per procedure.



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2. A Medication Pass observation was performed on 4/3/18 at 11:12 AM with EI # 7, RN. The medication was administered to an unsampled patient.

During the observation, EI # 7 entered patient room for administration of insulin. EI # 7 prepared insulin dose then donned gloves and administered insulin to the patient. EI # 7 failed to perform hand hygiene before donning gloves. Following the administration of the insulin, EI # 7 removed his/her gloves, and proceeded to adjust patient pillow and covers, without performing hand hygiene.

During an interview on 4/5/18 at 9:10 AM with EI # 1, Quality/Risk Management was notified of the failure to provide hand hygiene per facility policy.

3. A Medication Pass observation was performed on 4/4/18 at 8:17 AM with EI # 6, RN. The medication was administered to MR # 12 .

During the observation, EI # 6 entered the patient room then donned gloves without hand hygiene. EI # 6 then moved trash can to beside patient bed with gloved hand. EI # 6 then opened juice for patient and prepared medications. EI # 6 failed to remove gloves and perform hand hygiene after moving trash can with gloved hands. After administering oral medications, EI # 6 removes gloves then dons new pair of gloves to administer rectal medication without performing hand hygiene. EI # 6 then assist patient to position in the bed for administration of suppository rectally. After administration of suppository, EI # 6 removes gloves and dons new gloves without hand hygiene. EI # 6 then applies topical medication to patient buttocks. After applying topical medication, EI # 6 removes gloves then dons new gloves without hand hygiene to assist patient with positioning in bed.

During an interview on 4/5/18 at 9:10 AM with EI # 1, Quality/ Risk Management, confirmed the staff failed to provide hand hygiene per facility policy.

Based on review of policy, medical record (MR) and staff interview, the facility failed to ensure staff obtained signed physician orders for all care provided. This affected MR # 14, 1 of 2 out-patient rehabilitation plan of treatments reviewed.

Findings include:

Subject: Outpatient Therapy Request and Referrals
Reference # PT 0210; Reviewed: 2/18
Department: Physical Therapy

1. Patients are treated only upon written and signed prescriptions by physicians.
2. Outpatients are scheduled..for the initial evaluation. Additional treatment sessions are...scheduled through the physical therapy department.
3. Upon receipt of physician/s request for treatment...the Physical Therapist (PT)....evaluates the patient's condition.
4. The therapist completed the evaluation including the following information followed by a Plan of Care;
a. Treatment ordered...
c. Evaluation...Subjective Findings...Objective Findings...Assessment/Recommendations...Plans...Goals...
8. An up-dated physician prescription is required if there is a change in the...plan of care unless the initial prescription was..."evaluate and treat". In this care, a new prescription is not required...

11. This department will follow current CMS (Centers for Medicare and Medicaid Services) and private guidelines pertaining to treatment.

Record review revealed MR # 14 was referred to the outpatient department on 2/6/18 for PT to evaluate per protocol following a left total hip (revision), treat three times a week, weight bearing as tolerated with posterior precautions. The PT evaluation was performed on 2/9/18 and PT treatments were ordered 2-3 times a week.

There was no physician signature on the 2/6/18 treatment plan.

In an interview on 4/4/18 at 2:40 PM, Employee Identifier (EI) # 4 Director of Rehabilition Services reported Medicaid services did not require a physician signature on treatment plans. The surveyor asked for documentation from Medicaid that physician orders for care provided was not required.

On 4/5/18 at 11:00 AM, EI # 4 reported no such documentation could be located.

Based on review of facility policy, medical records (MR) and staff interview, it was determined the facility failed to ensure all interdisciplinary team staff completed comprehensive assessments and used the assessments to develop individualized plan of care for 2 of 3 swing bed records reviewed.

This affected MR # 14 and # 12 and had the potential to affect all patients treated on the transitional care unit.

Findings include:

1. MR # 14 was admitted to the transitional care unit on 12/7/17 with diagnoses including Status Post Cerebrovascular Accident with Left Side Hemiplegia.

Review of the initial Transitional Care Team Weekly Interdisciplinary Team dated 12/13/17 contained no documentation of patient/family education needs, progress towards clinical goals and medication issues were not addressed. The activities section were left blank and did not contain documentation of patient interests, frequency of participation, level of participation and issues/plans.

Record review revealed on 12/17/17 a foley catheter was inserted and the patient developed difficulty swallowing medications and on 12/19/17 a Speech Therapy evaluation was performed with recommendations for additional inpatient ST services.

Review of the second Transitional Care Team Weekly Interdisciplinary Team documentation dated 12/20/17 contained no medical status documentation, only "regressing" was documented, no documentation of activities participated in, no level of participation and no issues/plan for activities were documented. There was no nursing documentation for patient/family education needs, no progress towards clinical goals/issues/needs remaining and no medication issues were identified. There were no documentation weekly goal progress was completed by Occupational Therapy. There was no ST documentation only "See Eval (evaluation)" written across the document.

On 12/21/17 MR # 14 was discharged with home health services for Physical Therapy and Speech Therapy and nursing services with antibiotic infusion services ordered for 5 days of intravenous antibiotics.

In an interview on 4/5/18 at 8:56 AM, Employee Identifier (EI) # 2, Inpatient Care Services Director confirmed staff failed to ensure the weekly interdisciplinary team conference documentation was complete and reflected patient needs and patient progress.

2. MR # 12 was admitted to the transitional care unit on 3/22/18 with diagnoses including Status Post Left Hip Fracture with Pinning, Diabetes Mellitus Type 2 and Diabetic Neuropathy.

Medical record review revealed a critical low blood glucose on 3/25/18 with Metformin and Amaryl held and Lomotil was administered for diarrhea.

Review of the Initial Transitional Care Team Weekly Interdisciplinary Team documentation dated 3/28/18 revealed the Registered Nurse completed the activity section. There was no activity plan for the next 7 days documented.

Further review of the 3/28/18 Transitional Care Team Weekly Interdisciplinary Team documentation failed to include respiratory therapy progress or plans despite the patient being on oxygen 2 liters daily and nebulizer treatments for possible Pneumonia.

There was no nursing and/or medical documentation for the healing progress of the left hip surgical incision and medications were not addressed. The continued skill care needs of the patient was not completed by the nursing staff.

During an interview on 4/5/18 at 9:59 AM, EI # 2 confirmed the findings

Based on review of medical record (MR), Transitional Care Program admission agreement for activities, observation and staff interviews, it was determined the facility failed to ensure all patient activity needs and goals for care were met which included activity assessments completed, activities planned and organized and offered during normal waking hours.

This affected MR # 12 and # 14, 2 of 3 transitional care patient records reviewed and this had the potential to affect all patients admitted to the transitional care unit.

Findings include:

Transitional Care Program Admission Agreement

"...Activities

The Care Manager will evaluate your leisure needs, abilities and interests. Due to short inpatient program and the amount of therapy/treat,treatment on a daily basis, activities are individualized and more 1:1 or independent. A cart of activities will be offered to you at least twice a day every day of the week and you are encourage to request it more often if desired..."

Subject: Activity/Transitional Care
Department: Transitional Care Program; Reference: TC 0001
Reviewed: 5/2017

Policy:

" An ongoing activities program will be provided designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each resident...

Procedure:

A. An individuated assessment will be done for each patient by a qualified activity professional within 3 days of admission, an activities plan developed and documented on the care plan...
B. Activities coordinator will outline activities with a daily schedule for each patient.
C. Specific activities will be posted in the patients electronic health record.
D. The activity program will be reviewed by the attending physician and/or OT (Occupational Therapist). If there are any restrictions/precautions to the program, the physician and/or OT must indicated them and sign and date the Activity plan.
E. Reading materials, if appropriate, will be offered.
F. Nursing staff may carry out the activities program as outlined by the activities coordinator.
G. Documentation of participation in activities will be documented in the medical record.
H. Each patient will be encouraged to attend..."

****

During a tour of the medical floor on 4/3/18 at 9:30 AM, the surveyor observed a cart labeled "activity cart" at the nurse station. The cart contained word search, decks of cards, markers/colored pencils, children's coloring sheets, books, magazines and fingernail polish.

****

1. MR # 12 was admitted to the transitional care unit on 3/22/18 with diagnoses including Status Post Left Hip Fracture with Pinning, Diabetes Mellitus Type 2 and Diabetic Neuropathy.

Review of the Occupational Therapy activity assessment documentation dated 3/23/18 at 11:05 AM revealed activities of interest identified were watching television, visits from family, friends, pastor and staff. Patient needs and goals identified were socialization, emotional/spiritual support, fresh air and change of scenery.

There was no documentation the patient assessment included an explanation of the available activities offered by the facility and no documentation the Activity coordinator outlined facility activities using an activity schedule.

Record review revealed the Transitional Care Shift Activities Assessment completed by nursing staff contained documentation talking, conversing and television were completed and the activity cart was offered to the patient on the following dates/times:

3/23/18 at 12:01 PM
3/24/18 at 12:58 AM and 10:47 AM
3/25/18 11:25 AM and 8:00 PM
3/26/18 8:16 AM and 10:00 PM
3/27/18 3: 04 PM and 8:00 PM
3/28/18 9:22 AM and 8:00 PM
3/29/18 1:17 AM and 1:29 PM
3/30/18 12:06 AM and 10:00 AM
3/31/18 1:03 PM and 10:44 PM
4/1/18 9:52 AM and 10:30 PM
4/2/18 at 7:20 AM
4/3/18 at 12:32 AM and 7:45 AM

There was no documentation any activities other than talking/conversing and television were completed. Twice daily activities were not offered and documented on 3/23/18 and 4/2/18. On 3/24/18, 3/29/18, 3/30/18 and 4/3/18, activities were offered/performed in the early hours of the morning normally reserved for sleeping/resting which included offering the activity cart.

On 4/5/18 at 9:00 AM, the surveyor asked EI # 2, Inpatient Care Services Director for the monthly activity calendar schedule for March and April 2018. EI # 2 presented the surveyor with a document titled "Weekly Activities".

Sunday: devotional and daily reading;
Monday: play-doh workout and reminiscence;
Tuesday: crafts and play-doh workout;
Wednesday: reminiscence and crafts.
Thursday: puzzles and games.
Friday: games and movies.
Saturday: word puzzles.

There was no monthly March and April calendar provided to the surveyor. The following activities were documented and there was no scheduled activity times on the weekly calendar.

There was no crafts, movies, puzzles, or movies on the activity cart which were activities on the Weekly Activities calendar and no activity time (s) documented.

During an interview on 4/5/18 at 9:59 AM, EI (Employee Identifier) # 2, Inpatient Care Services Director confirmed the above findings. EI # 2 reported the Activity Coordinator hours were 7:00 PM to 7:00 AM, the Activity Coordinator maintained the activity cart and completed chart reviews.

2. MR # 14 was admitted to the transitional care unit on 12/7/17 with diagnoses including Status Post Cerebrovascular Accident.

Medical review revealed an OT Activities Assessment completed on 12/15/17 which was 8 days after the admission date. The facility staff failed to complete activity assessments within 72 hours.

On 12/15/17, the OT documented the patient activities of interest were watching television, visits from family, friends, pastor and hospital staff. Patient needs and goals documented were stimulus, get him/her to respond to stimulus.

There was no documentation the patient activity assessment included an explanation of the available activities offered by the facility. There was no documentation the Activity coordinator outlined activities using the activity schedule.

In an interview on 4/5/18 at 8:56 AM, EI # 2, Inpatient Care Services Director confirmed the above findings.

Based on medical records (MR) review and staff interviews, it was determined the facility failed to ensure staff was available and completed an Occupational Therapy (OT) evaluation/comprehensive assessment and provided ordered care to meet the patient needs.

This affected MR # 14 and # 11, which were 2 of 3 patients records reviewed admitted to the transitional care unit. This had the potential to affect all patients admitted to the transitional care unit.

Findings include:

1. MR # 14 was admitted to the transitional care unit on 12/7/17 with diagnoses including Status Post Cerebrovascular Accident with Left Sided Hemiplegia. The 12/7/17 physician orders included an OT consult.

Medical review revealed the OT Evaluation was completed on 12/15/17, which was 8 days after the admission date. The treatment plan revealed MR # 14 had left upper extremity flaccidity and OT treatment plans were 3 times a week for 3 weeks or until discharged.

There was no OT services available to the patient for 8 days.

In an interview on 4/5/18 at 8:56 AM, Employee Identifier (EI) # 2, Inpatient Care Services Director confirmed there was no backup coverage scheduled for OT coverage when part time, 3 day a week OT staff was not available for patient care.



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2. MR # 11 was admitted to the facility on 1/16/18 with diagnoses including Rehabilitation Secondary to Acute Systolic Congestive Heart Failure Exacerbation and Hypertension.

The physician orders on admission included orders for Occupational Therapy to evaluate and treat.

The OT evaluation was completed on 1/18/18. The evaluation documented patient to be seen: For 10 days or until discharge...

Medical record review revealed documentation of the OT assessment on 1/18/18 and 1/19/18. There was no documentation of any further OT treatments.

The patient failed to received the ordered OT care.

In an interview on 4/05/18 at 11:18 AM, EI # 4, Director of Rehabilition Services confirmed the above findings.