HospitalInspections.org

Based on medical record review, review of policy and procedure and staff interview, The CAH (Critical Access Hospital) failed to ensure the qualified professional for the activities program completed an activity assessment for individual activity interests for 5 of 5 Swing Bed in-patient records (25, 26, 27, 28 & 29) reviewed. This failed practice had the potential to affect all Swing Bed patients of the CAH. Total Swing Bed patient admits from 1/1/18-12/31/18 was 108.

Findings are:

A. Review of the following patient medical records revealed lack of evidence of an activity assessment for individual activity interests completed by a qualified professional:

- Patient 25's medical record (2/2719 at 2:15 PM) revealed a Swing Bed admission on 1/24/19.
- Patient 26's medical record (2/27/19 at 2:30 PM) revealed a Swing Bed admission on 2/14/19.
- Patient 27's medical record (2/27/19 at 2:45 PM) revealed a Swing Bed admission on 2/4/19.
- Patient 28's medical record (2/27/19 at 2:55 PM) revealed a Swing Bed admission on 2/20/19.
- Patient 29's medical record (2/27/19 at 3:00 PM) revealed a Swing Bed admission on 2/14/19.

B. Review of policy and procedure titled Quality of Life- Activities (Revised 8/16) stated "Upon admission to the Swing Bed, an Occupational Therapist will complete a comprehensive assessment of the patient's needs and interests through interpersonal communications with the individual and his/her family, medical records, observations, and/or recommendations of other staff."

C. Interview with the Chief Clinical Officer on 2/27/19 at 4:20 PM confirmed the missing activity assessments in the above medical records due to the assessment not "being completed at this time."

Based on medical record review and staff interview, The CAH (Critical Access Hospital) failed to ensure a comprehensive assessment of a Swing Bed patient's needs, strengths, goals, life history and preferences within 14 calendar days after admission for 2 of 2 Swing Bed in-patient records (25 & 27) reviewed. This failed practice had the potential to affect all Swing Bed patients of the CAH. Total Swing Bed patient admits from 1/1/18-12/31/18 was 108.

Findings are:

A. Review of the below medical records revealed a lack of evidence of a comprehensive assessment of a Swing Bed patient's needs, strengths, goals, life history and preferences:

- Patient 25's medical record (2/2719 at 2:15 PM) revealed a Swing Bed admission on 1/24/19.
- Patient 27's medical record (2/27/19 at 2:45 PM) revealed a Swing Bed admission on 2/4/19.

B. Interview with the Chief Clinical Officer on 2/27/19 at 4:20 PM confirmed the missing comprehensive assessments in the above medical records and stated the facility does not have a policy for completion of comprehensive assessments.