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Based on review of policy and procedures, medical record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that 1 of 20 acute inpatients (Patient 12), and 1 of 5 Swing Bed patients (Patient 32) had a completed nutrition assessment and diet order. This failed practice had the potential to affect all patients admitted to the CAH. The number of acute inpatient admissions was 56, and Swing Bed admissions was 26 from 9/20/2022-9/20/2023.

Findings are:

A. Review of policy and procedure titled Nutritional Assessment Program (Reviewed 8/2023) stated "The Consultant Dietician and the Nutrition Services Manager are responsible for initiating a nutritional assessment program on all long-term care patients and certain acute care patients who are experiencing high priority nutritional problems."

-Review of policy and procedure titled Swing Bed Nutritional Services (Reviewed 11/2022) stated "Based on a patient's comprehensive assessment, the facility will ensure that a patient maintains acceptable parameters of nutritional status, such as body weight and protein levels; unless the patient's clinical condition demonstrates that this is not possible."

B. Review of Patient 12's medical record (9/20/2023 at 10:36 AM) revealed an acute inpatient admission of 3/25/2023-4/10/2023 for Transient Ischemic Attack (TIA-a temporary blockage of blood flow to the brain), Hyponatremia (low sodium level), multiple (6-7) open areas on perineum area, Aortic Stenosis (The aortic (heart) valve does not open fully which decreases blood flow to the heart). A review of the entire medical record revealed on 3/25/2023 at 12:58 PM Patient 12 was documented as a high risk and indicated a referral for a nutrition assessment.

-Review of Patient 32's medical record (9/20/2023 at 1:25 PM) revealed a Swing Bed admission of 5/8/2023-5/16/2023 for Adult Failure to Thrive (loss of appetite, eats or drinks less than usual, loses weight), and Weakness. A review of the entire medical record lacked evidence of a diet order and lacked a completed nutrition assessment.

C. Interview with the Director of Health Information Management (HIM) (9/20/2023 at 10:45 AM) confirmed that Patient 12's medical record lacked evidence of a completed nutrition assessment.

-Interview with the Director of HIM (9/20/2023 at 2:11 PM) confirmed that Patient 32's medical record lacked evidence of a diet order and a completed nutrition assessment.

Based on medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the Important Message from Medicare was received and signed before discharge for 9 out of 20 inpatients (Patients 1, 5, 7, 9, 10, 11, 12, 13, 14) reviewed, and 4 out of 5 Swing Bed patients (Patients 32, 33, 34, 35) reviewed. This failed practice had the potential to affect all patients admitted to the CAH. The number of inpatient admissions was 56 and Swing Bed was 26 from 9/20/2022-9/20/2023.

Findings are:

A. Review of Patient 1's medical record (9/19/2023 at 9:08 AM) revealed an inpatient admission of 5/24/2023-5/25/2023 for a Ground Level Fall resulted in a fracture of the femur (broken bone in the leg). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 5's medical record (9/19/2023 at 11:49 AM) revealed an inpatient admission of 1/24/2023-1/27/2023 for a Fall which resulted in a fracture of the right humerus (broken arm bone), and left patella (broken knee bone). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 7's medical record (9/19/2023 at 1:01 PM) revealed an inpatient admission of 6/19/2023-6/23/2023 for Cellulitis of the Right Lower Leg (Bacterial skin infection). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 9's medical record (9/19/2023 at 1:40 PM) revealed an inpatient admission of 2/27/2023-3/2/2023 for Fall with right hip pain. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 10's medical record (9/19/2023 at 3:55 PM) revealed an inpatient admission of 3/3/2023-3/4/2023 for Alcoholic Cirrhosis of Liver without Ascites (the liver is scarred/permanently damaged from drinking alcohol), Altered Mental Status (change in memory/mental function). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 11's medical record (9/19/2023 at 4:13 PM) revealed an inpatient admission of 3/4/2023-3/5/2023 for Pathological Fracture of Neck of Right Femur (Broken right leg), Mobitz type II atrioventricular block (slowed heart rate due to the heart's electrical system not working properly). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 12's medical record (9/20/2023 at 10:36 AM) revealed an acute inpatient admission of 3/25/2023-4/10/2023 for Transient Ischemic Attack (TIA-a temporary blockage of blood flow to the brain), Hyponatremia (low sodium level), multiple (6-7) open areas on perineum area, Aortic Stenosis (The aortic (heart) valve does not open fully which decreases blood flow to the heart). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 13's medical record (9/20/2023 at 11:05 AM) revealed an inpatient admission of 3/10/2023-3/11/2023 for Upper Gastrointestinal Bleed (bleed in the tube that moves food from the mouth to the stomach). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 14's medical record (9/20/2023 at 11:30 AM) revealed an inpatient admission of 3/29/2023-4/4/2023 for Portal Hypertension (high pressure in the major vein that leads to the liver), Hepatic Encephalopathy (The liver doesn't work properly, causing toxins to build up in the blood leading to brain damage), and Volume Depletion (low fluid volume in the body). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 32's medical record (9/20/2023 at 1:25 PM) revealed a Swing Bed admission of 5/8/2023-5/16/2023 for Adult Failure to Thrive (loss of appetite, eats or drinks less than usual, loses weight)), and Weakness. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 33's medical record (9/20/2023 at 2:18 PM) revealed a Swing Bed admission of 4/11/2023-5/11/2023 for post operation of Open Reduction and Internal Fixation (ORIF-puts pieces of a broken bone into place using pins in the operating room by a surgeon) related to a hip fracture (surgical procedure to repair a broken hip bone). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 34's medical record (9/20/2023 at 3:59 PM) revealed a Swing Bed admission of 7/14/2023-7/31/2023 for post operation of ORIF left elbow (puts pieces of a broken bone into place using pins in the operating room by a surgeon) related to a left elbow fracture (broken bone in the elbow). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 35's medical record (9/20/2023 at 4:18 PM) revealed a Swing Bed admission of 6/282023-7/13/2023 Cerebrovascular accident (CVA) of the left thalamus (interruption of blood flow to part of the brain that affects hearing, taste, sight, and touch). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

B. Interview with the Director of Health Information Management (HIM) (9/21/2023 at 8:11 AM) confirmed that the above medical records lacked evidence of an Important Message from Medicare notice signed before discharged.