HospitalInspections.org

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to assure staff who provide services in the Emergency Department (ED) are certified as required by the CAH's policies. The deficient practice affected four of four staff nursing and respiratory staff members identified by the CAH as working in the ED and seven of the eight physician-employees who provide ED services.

Findings include

- The CAH's policy titled Emergency Room Nursing Care, reviewed on 11/2/11 at 1:30pm, directs "Emergency Room Nurses, as well as any employee functioning within the Emergency Department, shall have current CPR (cardiopulmonary resuscitation), PALS (Pediatric Advance Life Support), ACLS (Advance Cardiac Life Support), and TNCC (Trauma Nursing Core Course).

- Administrative staff A, interviewed on 11/2/11 at 2:45pm confirmed the nursing staff and physicians are employees of the CAH.

- Administrative nurse B's personnel record, reviewed 11/2/11 at 10:30am revealed the lack of current CPR, PALS, ACLS and TNCC certification.

- Nursing staff G's personnel record, reviewed 11/2/11 at 10:30am, revealed the lack of current PALS and TNCC certification.

- Nursing staff J's personnel file, reviewed 11/2/11 at 10:30am, revealed the lack of evidence of PALS certification.

- Physician V's credentialing file, reviewed on 11/2/11 at 2:45pm revealed the lack of evidence of CPR, ACLS, PALS and TNCC certification as required by CAH policy.

- Physician W's credentialing file, reviewed on 11/2/11 at 2:45pm revealed the lack of evidence of CPR, ACLS, PALS and TNCC certification as required by CAH policy.

- Physician X's credentialing file, reviewed on 11/2/11 at 2:45pm revealed the lack of evidence of CPR, ACLS, PALS and TNCC certification as required by CAH policy.

- Physician Y's credentialing file, reviewed on 11/2/11 at 2:45pm revealed the lack of evidence of CPR, ACLS, PALS and TNCC certification as required by CAH policy.

- Physician Z's credentialing file, reviewed on 11/2/11 at 2:45pm revealed the lack of evidence of CPR, ACLS, PALS and TNCC certification as required by CAH policy.

- Physician AA's credentialing file, reviewed on 11/2/11 at 2:45pm revealed the lack of evidence of CPR, ACLS, PALS and TNCC certification as required by CAH policy.

- Physician BB's credentialing file, reviewed on 11/2/11 at 2:45pm revealed the lack of evidence of CPR, ACLS, PALS and TNCC certification as required by CAH policy.

Based on observation, staff interview and policy review the Critical Access Hospital (CAH) failed to assure housekeeping and preventative maintenance for all mechanical and patient care equipment for 1 or 1 kitchen stove ventilator hood and 1 of 1 convection oven.

Findings include:

- Observation on 10/31/11 at 9:55am in the dietary department revealed a heavy accumulation of debris and dust covering the coils of the stove ventilator hood. The convection oven ledge below the switches had brown loose debris.

Dietary staff P interviewed on 10/31/11 at 9:55am acknowledged the dust and debris on the ventilator hood and convection oven. Staff P acknowledged the maintenance department removed the coils for the ventilator hood every two months for cleaning and lacked knowledge of the last cleaning of the ventilator hood.

Maintenance staff S interviewed on 11/2/11 at 2:00pm revealed the CAH lacked a preventative maintenance schedule for cleaning of the dietary department's ventilator hood and only removed the coils when the dietary staff reported the need to clean the ventilator hood. Staff S failed to have documentation of the last cleaning of the ventilator hood.

Administrative staff A interviewed on 11/2/11 at 3:30pm revealed the CAH failed to have a policy directing staff on cleaning of the stove ventilator hood and provided a copy of a policy they had wrote on 11/2/11 for "Cleaning Hoods and Filters" .

The CAH failed to have a system in place to assure preventative maintenance of the dietary ventilator hood.

Based on observation, document review and interview, the Critical Access Hospital (CAH) failed to properly store medications, and failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices. This deficient practice had the potential to affect all patients, staff, and visitors of the Critical Access Hospital (CAH).


Findings include:


- The CAH failed to ensure drugs are stored correctly as evidenced at C- 276, CFR 485.635(a)(3)(iv).


- The CAH failed to ensure the infection control officer developed and implemented an active infection control system to identify, report, investigate, monitor, and implement infection control practices as evidenced at C-278, CFR 485.635(a)(3)(ii).

The Critical Access Hospital (CAH) reported an average census daily census of 2.9 patients. Based on observation, interview and document review, the CAH failed to ensure drugs are stored correctly in two areas of the CAH.

Findings include:

- The Computed Tomography (CT) room of the radiology department, observed on 10/31/11 at 12:00pm, revealed a warming cabinet. The warming cabinet contained 17 vials of 100cc's/vial CT contrast media (an intravenous dye used during a CT scan) and 13 vials of 50cc's/vial of contrast media. A 1000cc (cubic centimeter) of normal saline, with the date written directly on the bag with a marker, hanging on the infuser next to the CT scanner. The bag contained approximately 900cc's of fluid. Staff H confirmed the normal saline is used during the administration of the CT contrast and stated the bag is used for each patient who has a CT scan for the day. The normal saline bag is labeled by the manufacturer as "single patient use". Staff H confirmed the bag is used for each CT scan performed with the contrast for the day and lacked awareness the bag of fluid is labeled for single patient use.

- The Central Supply store room, observed on 11/3/11 at 10:30am revealed the following medications. Each bag or bottle contained a manufacturer's label directing by prescription only.
Dextrose 5% (a sugar solution) and 0.9% Normal Saline (NS-a salt solution) 1000cc (cubic centimeters)- 3 bags, Dextrose 5% in water- 1000cc- 15 bags, Dextrose 5% in .45% NS 1000cc- 8 bags, NS .45% 1000cc - 8 bags, Lactated Ringers (an electrolyte solution) 1000cc- 26 bags, NS .9% 1000cc- 24 bags, Dextrose 5% in 33% NS 1000cc- 2 bags, Dextrose 2% in NS 1000cc- 2 bags, Dextrose 5% in Lactated Ringers 1000cc- 20 bags, NS 9% 250cc- 12 bags, NS 9% 100cc- 20 bags, NS 9% 50cc- 20 bags, NS 250cc- 4 bags, 5% Dextrose 250cc- 8 bags, Dextrose 5% 100cc- 15 bags, Dextrose 5% 1000cc- 15 bags, .45%NS 50cc- 26 bags, 0.9% NS 50cc- 50 bags, 0.9% NS 100cc- 118 bags, NS 50cc- 97 bags, NS l00cc 480 bags, NS 250cc- 72 bags, NS 250cc- 52 bags, NS 1000cc- 48 bags.

The Central Supply storeroom, observed on 11/3/11 at 10:30am, contained Sterile water for irrigation 1000cc -62 bottles and Normal Saline for irrigation 1000cc- 84 bottles,
Thoracentesis trays (used to insert a need) 12 trays with Lidocaine 5%- 5cc vial in each tray and Epidural injection trays(used in pain management injections) 9 trays with Lidocaine 5%- 5cc vial in each tray.


Pharmacist E, interviewed on 11/2/11 at 10:30am confirmed the bag of intravenous fluid is labeled for single patient use only, acknowledged the lack of awareness of the bag of IV fluid used for more than one patient, and confirmed their failure to visit all areas of the hospital where medications are stored.

Pharmacist E confirmed the CAH failed to ensure supervision of medications administered in the Radiology Department to assure the CAH followed the manufacturer ' s instructions for medication administration.

- The manufacturer ' s instructions for the use of the intravenous tubing set used to administer the CT contrast, reviewed on 11/9/11 at 3:30pm, revealed the tubing is not intended to be used to administer " single patient use " only IV solutions to multiple patients. The tubing is intended to transfer multiple doses of CT contrast from a multiple dose vial supply to syringes for patient administration.

- Staff A, interviewed by telephone 11/10/11 at 9:45am, confirmed the CAH reviewed their practice of re-using ' single patient only ' items for more than one patient and have discontinued the use of the IV tubing to administer the IV solution to more than one patient.

- The CAH's policy titled "Unit Inspection" reviewed on 10/31/11 at 3:55pm, revealed "all areas of the hospital where medications are stored will be checked in a monthly basis..." and "This will be done to determine that proper supplies are maintained, medications are stored under proper conditions...".

- The CAH's policy titled "Medication Security" reviewed on 10/31/11 at 3:55pm revealed "all drugs...will be stored in lockable containers or in secure area".

Pharmacist E, interviewed on 11/2/11 at 11:30pm confirmed they lacked knowledge of where the CAH stores all medications and who dispenses the medications.

- The CAH lacked evidence of the pharmacist's job description when requested by the surveyor.

- State Board of Pharmacy inspector, interviewed on 11/3/11 at 9:30am confirmed any medication with a label that indicates "By RX only" is a pharmacy item and is to be stored and dispensed following State of Kansas Pharmacy Regulations.

Based on observation, staff interview, and policy review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices. This deficient practice had the potential to affect all patients, staff, and visitors of the Critical Access Hospital (CAH).

Findings include:

- Review of the Infection Prevention Surveillance Activities on 10/31/11 at 3:45pm directed "...It is the policy and practice of the hospital to have a well structured surveillance system to assess the quality of patient care and hospital support activities to promote effective infection prevention practices ...".

Staff B interviewed on 11/1/11 at 1:35pm verified they were responsible for the management of the infection control program. The CAH's infection control committee reviews policies and procedures and approves hospital wide cleaning products. Staff B acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control. Staff B's infection control surveillance is based on patient assessment, antibiotic use, and lab reports to track patient infections. The infection control officer reports to the Governing Body on a quarterly basis. Staff K, the infection control officer's assistant, acknowledged the CAH failed to develop and implement a surveillance program for infection control practices and the lack of documentation of staff education on hand hygiene practices and cleaning of equipment.

Review of staff education for hand hygiene on 11/2/11 at 10:30am revealed the CAH utilized computer education for staff and the last documented hand hygiene education occurred over one year ago.

Staff B interviewed on 11/2/11 at 2:40pm reported they conducted hand hygiene education this past year and was unable to provide documentation of the education or an attendance roster.

- Observations during the survey process revealed the following breaches in infection control practices regarding sanitizing of items in the dietary department, hand hygiene, cleaning of patient care equipment, and monitoring of the negative airflow room.

- The CAH's policy for "Manual Warewashing" (a three-compartment sink dishwashing method) reviewed on 10/31/11 at 3:10pm directed "...Immerse items in the third sink in hot water or a chemical-sanitizing solution. If chemical sanitizing is used, the sanitizer must be mixed at the proper concentration ...check the concentration of the sanitizing solution at regular intervals with a test kit ...".

- Staff R was observed on 10/31/11 at 10:30am washing cooking utensils at the three-compartment sink in the dietary department. Staff R explained the first sink contained soap and water to clean the dishes, the second sink contained rinse water, and the third sink contained a sanitizing agent to sanitize the clean dishes. Staff R verified the sanitizing solution required testing with test stripes to confirm proper concentration to insure sanitization. Upon request by the surveyor Staff R tested the sanitization water and the test reached a PH of less than 150ppm (parts per million) concentration. Review of the manufactures recommendations for testing the third sink sanitization instruct " ...solution should be 200ppm concentration. Documentation on the wall by the three-compartment sink revealed the third compartment sink testing occurred at breakfast, lunch, and supper, not each time the third-compartment sink was used.

- The CAH's policy for hand hygiene reviewed on 11/1/11 at 3:40pm directed "...hands are the conduits for almost every transfer of potential pathogens from on patient to another ...Hand hygiene is the single most important procedure in preventing infection ...hand hygiene must be performed ...before direct patient contact, after removing gloves, before inserting an invasive device, after contact with the patient, after contact with body fluids, after contact with inanimate objects in the patient's room ..."

- Respiratory staff N observed on 10/31/11 at 10:50am entered room #208 to provide an aerosol treatment. Staff N failed to perform hand hygiene prior to the aerosol treatment on patient #12. Staff N completed the aerosol treatment, left the room and failed to perform hand hygiene. Staff N returned to the nurses' station and documented the aerosol treatment on the computer.

- Nursing staff L observed on 10/31/11 at 1:30pm entered room #208 to administer a bag of intravenous (IV) medication. Staff L failed to perform hand hygiene prior to the hanging the bag of IV solution for patient #12 or when leaving the room. Staff L returned to the nurses' station.

- The CAH's policy for blood glucose monitoring (using a glucometer a machine to test blood sugars) reviewed on 11/1/11 at 3:40pm directed "...perform hand hygiene, put on gloves, after collecting the blood sample and test results, remove test strip and dispose of it, remove gloves and perform hand hygiene ...".

- The manufactures' instructions for cleaning the one step glucometer, posted at the nurses station and reviewed on 11/2/11 at 9:00am, directed " ...clean your meter with 70% alcohol ... ". A note added to the instructions directed staff to use alcohol wipes or sani-wipes (a disinfecting wipe) between patient use.

- Nursing staff L observed on 10/31/11 at 2:00pm obtained a glucometer at the nurses station, entered patient #16's room, failed to perform hand hygiene, laid the glucometer case on the bed without a protective barrier, removed the glucometer and laid it directly on the patient's bed without a protective barrier. Staff L picked up the glucometer from the patient's bed, obtained the blood sugar test results, picked up the glucometer case removed the blood contaminated test strip from the glucometer without the protective barrier of gloves, and then placed the glucometer back in the case. Staff L left patient #16's room and failed to perform hand hygiene or clean the glucometer and case. Staff L returned to the nurses' station and placed the glucometer in the medication room. The glucometer was available to patient use.

Staff L, interviewed on 5/9/11 at 12:20pm, acknowledged they laid the glucometer and case on patient #16's bed and failed to clean the equipment between patients.

- Nursing staff M observed on 10/31/11 at 2:30pm entered the nurses' station wearing gloves, reported a test to nursing staff L, removed their gloves, placed their foot on a chair to retied their shoe, and remained at the nurses' station. Staff M failed to perform hand hygiene or clean the chair where they placed their soiled shoe.

- Nursing staff M observed on 11/1/11 at 9:45am in patient #14's room obtained vital signs using a vital sign machine and blood pressure cuff. When staff M left the room, they failed to perform hand hygiene. Staff M moved the vital sign machine into an empty patient room and failed to clean the vital sign machine or blood pressure cuff between patients.

- Nursing staff M observed on 11/1/11 at 10:21am entered patient #11's room and failed to perform hand hygiene. Staff M removed oxygen tubing from the wall and attached it to a portable oxygen tank. The oxygen tank failed to function and staff M placed the patient back on wall oxygen. Staff M left the patient room with the empty oxygen tank and failed to perform hand hygiene. Staff M placed the empty oxygen tank in the medical record chart room, returned to patient #11's room with a new oxygen tank, and failed to perform hand hygiene.

- Rehabilitation staff Q observed on 11/2/11 at 8:40am in patient #11's room providing services. Staff Q completed their services, left the patient room, and failed to perform hand hygiene.

Staff Q interviewed on 11/2/11 at 8:45am acknowledged they failed to perform hand hygiene and usually performed hand hygiene when they returned to their department. Staff Q acknowledged they touched the door handle and stairway handle after treating patient #11 and before returning to their department to perform hand hygiene.


- Patient #34's clincial record, reviewed on 11/2/11 at 8:30pm, revealed the patient was admitted to the hospital with nausea, vomiting and a lung mass on 10/10/11. The physician ordered "reverse isolation" with laboratory tests pending. The CAH staff moved the patient to room 200 to use the negative pressure air flow.

Review of the CAH's documentation of the verification the negative air flow room was functioning correctly was dated 12/10. Infection Control Officer staff C, interviewed on 11/2/11 at 3:30pm confirmed the CAH lack evidence of checking to assure the room functioned correctly.

Respiratory care staff N, interviewed on 11/2/11 at 3:35pm, stated they performed the negative pressure room check during 12/10. Staff N confirmed the CAH lacked a procedure to perform the room checks.

Maintenance staff S, interviewed on 11/2/11 at 3:40pm stated repairs had been made and the room functioned correctly. Staff S confirmed the CAH lacked a procedure to perform the room checks.

The CAH failed to develop and implement a policy and/or procedure to assure the negative air flow room is functioning correctly and assure Infection Control Staff are aware of any issues.

- Patient #34's clinical record, reviewed on 11/2/11 at 3:30pm revealed the hospital admitted a patient who required "reverse isolation" be moved to the negative air flow room 200, on 10/10/11. The CAH lacked evidence the room functioned correctly to protect the patient, staff and visitors as ordered by the physician.

- Observation in the mammogram room on 10/31/11 at 12:15pm, revealed a radiology staff member cleaning the surfaces the patient touches during a mammogram with Clorox wipes. The surface remained wet with the disinfectant solution for less than one minute. Information presented by radiology staff and reviewed on 10/31/11 at 12:20pm, revealed Clorox is to remain in contact with the surface for 4 minutes to disinfect.

- Review of the manufacturer's guidelines for the use of the Virex 256 One-Step Disinfectant cleaner on 11/3/11 at 9:45am stated, "To disinfect hard, non-porous surfaces, treated surfaces must remain wet for 10 minutes".

- Observation of the laundry room during the environmental tour of the CAH on 11/1/11 between 9:00am to 10:50am revealed staff U loading the dirty laundry into the two washing machines. Staff U after loading the washing machines sprayed the front of the washing machines with Virex 256 and immediately wiped the solution off with a dry cloth. Staff U explained they spray the handle, door, and front of the washing machines with the Virex 256 after they put the dirty laundry in the washing machines.

Staff T, administrative staff, interviewed on 11/1/11 at 10:40am acknowledged the staff cleaned the front of the washers after loading them with the dirty laundry to prevent cross contamination with the clean laundry.

Staff S, administrative staff, interviewed on 1/3/11 at 10:10am acknowledged staff U sprayed the surfaces of the washing machines, dried them immediately and failed to follow the manufacturer's guidelines.

The CAH failed to assure the laundry staff disinfected the washing machines according to the manufacturer's directions to prevent cross contamination of the clean and dirty laundry.

- The hospital failed to assure staff followed hand hygiene, equipment cleaning, and basic infection control practices to protect staff, patients and visitors from potentially infectious microorganisms.

Based on policy review, medical record review, and staff interview the Critical Access Hospital (CAH) failed to ensure completed entries in the medical records and failed follow their policy for 5 of 13 delinquent, closed medical records reviewed (patient #'s 20, 23, 25, 26, and 28).

Findings include:

- The CAH's policy titled "Notification to Physician Concerning Delinquent Records" reviewed on 11/2/11 at 1:15pm stated, "...All records should be completed by the 30th day following the patient's discharge from the hospital."

- Patient #20's closed medical record reviewed on 11/1/11 at 12:45pm revealed an admission date of 4/17/11 with a diagnosis of Transfusion Reaction (a negative response to a blood transfusion) and a discharge date of 4/22/11. Patient #20's medical record revealed a History and Physical dictated on 4/18/11 and signed by the physician on 6/17/11. The physician failed to complete the medical record by the 30th day following the patient's discharge from the hospital per the CAH's policy.


- Patient #23's closed medical record reviewed on 11/1/11 at 2:30pm revealed an admission date of 5/30/11 with diagnoses of Chronic Bronchitis (difficulty breathing) and a discharge date of 6/2/11. Patient #23's medical record revealed a discharge summary dated 6/2/11 and signed by the physician on 7/13/11. The physician failed to complete the medical record by the 30th day following the patient's discharge from the hospital per the CAH's policy.

- Patient #25's closed medical record reviewed on 11/2/11 at 7:45am revealed an admission date of 7/18/11 with diagnoses of Urinary Tract Infection, and pressure ulcer and a discharge date of 8/1/11. Patient #25's medical record revealed a History and Physical dictated and typed on 7/18/11 lacked the physician's signature. The physician failed to complete the medical record by the 30th day following the patient's discharge from the hospital per the CAH's policy.

- Patient #26's closed medical record reviewed on 11/2/11 at 8:30am revealed an admission date of 9/23/11 with Atrial Fibrillation with Rapid Ventricular Response (RVR) ( rapid beating of the heart) and a discharge date of 9/24/11. Patient #26's medical record revealed a History and Physical dictated on 9/23/11 and typed on 9/26/11 lacked the physician's signature. The physician failed to complete the medical record by the 30th day following the patient's discharge from the hospital per the CAH's policy.

- Patient #28's closed medical record reviewed on 11/2/11 at 10:30am revealed an admission date of 9/27/11 with a diagnosis of Digestive System Complication and a discharge date of 10/1/11. Patient #28's medical record revealed a Discharge Summary dictated on 10/1/11 and typed on 10/2/11 lacked the physician's signature. The physician failed to complete the medical record by the 30th day following the patient's discharge from the hospital per the CAH's policy.

Staff D interviewed on 11/2/11 at 10:15am acknowledged the CAH failed to assure the physicians completed the medical records per the CAH's policy.

Based on observation, document review and staff interview, the Critical Access Hospital (CAH) failed to ensure a complete medical record for one of one patient observed during an outpatient procedure (patient #33).

Findings include:

- Patient #33, observed on 11/1/11 at 2:30pm during with physician T, revealed the patient received an epidural injection (used for pain management in the lower back). Physician T administered doses of Lidocaine (a local anesthetic) during the injection. Staff F, interviewed following the procedure, confirmed the patient received Lidocaine. Patient #33's clinical record lacked evidence of the administration of Lidocaine.

The CAH's policy titled "Medication Administration", reviewed on 10/31/11 3:55pm, failed to direct staff that all medications administered will be documented in the patient's clinical record.

Based on observation, document review and staff interview, the Critical Access Hospital (CAH) failed to protect patient records from unauthorized access.

Findings include:

- Observation of the the CAH's reception desk/radiology film storage area in the radiology department on 10/31/11 at 12:00pm, revealed a window to a patient waiting area and a door into a hallway with an entrance which may be used by patients and visitors. The room contained 60 shelves with approximately 200 sleeves of x-ray films on each shelf.

- The CAH's policy, titled "Security of Information", reviewed on 11/2/11 at 9:00am revealed the CAH failed to address the protection and storage of radiology films.

- Staff D, interviewed 11/2/11 at 10:30pm confirmed the radiology films contained protected health information and are to be secured from unauthorized use.

- Observation of the hallway on 11/2/11 at 11:30pm with staff E, revealed a patient or visitor walking in the hallway radiology department without CAH staff present to assure the records were secured.

Based on staff interview, observation and document review the Critical Access Hospital (CAH) failed to develop and implement an effective Quality Assurance Performance Improvement (QAPI) Program.

Finding include:


- The CAH failed to provide evidence of policies and procedures to carry out or arrange for a periodic evaluation of its program as evidenced at C-331, CFR 485.641.

- The CAH failed to determine whether the utilization of services provided by the CAH were appropriate, if the established policies were followed and if any changes were needed as evidenced at C-335, CFR 485.641(a)(2).

- The CAH failed to identify and monitor staff and environmental infection control issues and/or problems as evidenced at C-337 485.641(b)(1).

\

Based on staff interview and the lack of documents for review, the Critical Access Hospital (CAH) failed to provide evidence of policies and procedures to carry out or arrange for a periodic evaluation of its program.

Findings include:

- Administrative staff A, interviewed on 11/2/11 at 2:00pm confirmed the lack of policies and procedures directing the CAH to arrange for or perform an annual review of its total program and lacked evidence of the program evaluations.

The CAH failed to provide evidence of an annual program evaluation.

Based on staff interview and the lack of documents for review, the Critical Access Hospital (CAH) failed to determine whether the utilization of services provided by the CAH were appropriate, if the established policies were followed and if any changes were needed.

Findings include:

- Administrative staff A, interviewed on 11/2/11 at 2:00pm confirmed the CAH lacked evidence of an annual program evaluation, evidence of the utilization were appropriate, if policies were followed and if any changes were needed.


- The CAH failed to provide evidence of an annual program evaluation.

Based on Performance Improvement Plan review, Quality Committee meeting minutes reviewed and staff interview the Critical Access Hospital (CAH) failed to identify and monitor staff and environmental infection control issues and/or problems and failed to include infection control issues/or problems in their Quality Assurance/Performance Improvement (QA/PI) program.

Findings include:

- The CAH's Performance Improvement Plan reviewed on 11/2/11 at 11:30am revealed under " Program Goals, #2, The desired outcomes of the Program are to assure the continuous identification of opportunities to drive higher level of quality, efficiency and effectiveness into everything that impacts the delivery of patient care and the relationships with our communities".

- Review of the Quality Committee meeting minutes on 11/2/11 at 11:30am lacked evidence of the identification or monitoring of infection control issues and/or problems.

- Staff B interviewed on 11/1/11 at 1:35pm acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control.

- Staff C interviewed on 11/3/11 at 11:00am acknowledged the CAH failed to include infection control issues and/or problems in their QA/QI program.

Based on policy review, medical record review and staff interview the Critical Access Hospital (CAH) failed to provide evidence of activities for 5 of 5 sampled swing bed residents (#'s 11, 12, 13, 14, and 15).

Findings include:

- The CAH's policy "Activities/Activities Assessment" reviewed on 11/1/11 at 11:15am directed "...It is the desire and intent to establish an activities program as part of the Swingbed Program to provide physical and mental stimulation for patients confined to the hospital ...based on a comprehensive assessment of each Swingbed patient ...Activities will be available seven days a week ... "

- Patient #11's medical record reviewed on 10/31/11 at 11:15am revealed an admission on 10/24/11 with a diagnosis of Cerebral Vascular Accident (stroke). The medical record lacked evidence of an activities assessment, care plan addressing activities, or documentation activities were conducted.

- Patient #12's medical record reviewed on 10/31/11 at 11:40am revealed an admission on 10/14/11 with a diagnosis of a Left Femoral Deep Vein Thrombosis (blood Clot of the upper leg). The medical record lacked evidence of an activities assessment, care plan addressing activities, or documentation activities were conducted.

- Patient #13's medical record reviewed on 10/31/11 at 12:00pm revealed an admission on 10/27/11 with a diagnosis of dehydration. The medical record lacked evidence of an activities assessment, care plan addressing activities, or documentation activities were conducted.

Staff O interviewed on 3/10/11 at 1:20pm acknowledged they were responsible for activities for swing bed residents and failed to assess and provide documentation of activities provided to the swing bed residents.

This deficient practice also affected patient's #14 and #15.