HospitalInspections.org

Based on a review of documents and interview it was determined that the facility failed to annually review health care policies.

Findings were:
A facility policy manual entitled "Nursing Division Emergency Department Policy & Procedure Manual" was reviewed on 11/24/10. This manual indicated that these policies were last reviewed on 9/16/09.

During an interview with the Director of Nursing on 11/24/10 she stated that they are in the process of updating these policies, and the review was set to be completed during next month.

A facility policy manual entitled "Nursing Division Policy and Procedure Manual" was reviewed on 11/24/10. This manual indicated that these policies were last reviewed on 8/2009.

During and interview with the Director of Nursing on 11/24/10 she stated that these policies have been updated and are scheduled for review during the next month.

A facility policy manual entitled "Disaster Plans Policy and Procedure Manual" was reviewed on 11/24/10. This manual indicated that several policies were last reviewed on 6/2007.

During an interview with the Assistant Director of Nursing on 11/24/10 she confirmed the above findings.

Based on review of documents and interview it was determined that the facility failed to include the reason for discharge, a statement that the resident has the right to appeal the action to the State, and the name, address and telephone number of the State long term care ombudsman for 4 of 4 closed swing bed charts reviewed.

Findings were:
Review of the medical records for patients 1, 2, 3 and 6 on 11/24/10 revealed that they were admitted to and discharged from the facility's swing bed program. There was no documentation found by or provided to the surveyor indicating that these patients were provided with the following information upon discharge from the facility's swing bed program: ? The reason for discharge
? A statement that the resident has the right to appeal the action to the State.
? And the name, address and telephone number of the State long term care ombudsman.

The above information was confirmed in an interview with the Director of Nursing on 11/24/10.

Based on review of documents and interview it was determined that the facility failed to complete an activity assessment and activity plan for 1 of 4 swing bed records reviewed.

Findings were:
Review of patient #6 ' s medical record on 11/24/10 revealed that the patient was admitted as a swing bed patient for approximately 4 days. There was no activity assessment or activity plan found by or provided to the surveyor.

During an interview with the Director of Nursing she confirmed the above finding and stated that an activity assessment and activity plan should have been completed within 24 hours of patient #6 being admitted as a swing bed patient.