HospitalInspections.org

The hospital reported a census of 3 patients. Based on document review and staff interview the Critical Access Hospital (CAH) failed to ensure the governing body affirm, deny, or modify medical staff privileges for two of seven credentialing files reviewed (staff K and L). This deficient practice has the potential to place all patients at risk of receiving treatment from unqualified medial staff.



Findings include:


- Medical Staff bylaws reviewed 8/5/2015 at 9:00 AM directed"... The Governing Body shall ultimately be responsible for granting membership and privileges... and ... Review for reappointment is required every two years..."


Medical staff L's credentialing file reviewed on 8/4/2015 at 2:30 PM revealed reappointment last completed 4/23/2012.


Medical staff K's credentialing file reviewed on 8/4/2015 at 3:00 PM revealed credentialing application completed 7/19/2010, reappointment application dated 10/27/2012 remained incomplete, and reappointment application submitted 9/24/2014 with a completion date of 3/2015 following the Governing body's approval.


Staff H interviewed on 8/5/2015 at 3:15 PM acknowledged the CAH failed to complete the reappointment process within the required two-year timeframe.

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the hospital was maintained in a manner to ensure the safety of patients in thirteen of thirteen patient rooms. This deficient practice had the potential to affect the health of all current and future patients of the CAH.


Findings include:


Room # 102 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt, a plastic toilet paper holder with a white film coating the surface and corner ceiling tiled with brownish stain.

Room # 103 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt and a plastic toilet paper holder with a white film coating the surface.

Room # 104 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt, a plastic toilet paper holder with a white film coating the surface and a wooden room door with long strips of wood missing.

Room # 105 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt, a plastic toilet paper holder with a white film coating the surface, a two stained ceiling tiles.

Room # 106 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt and a plastic toilet paper holder with a white film coating the surface

Room # 107 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt, a plastic toilet paper holder with a white film coating the surface and a vinyl chair with small tear on the left armrest.

Room # 108 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt and a plastic toilet paper holder with a white film coating the surface and a wall-mounted basket with rust showing. The west wall contained a large tear in the drywall approximately 4" long x 2" wide and multiple small tears. The room contained two non-cleanable cloth-covered reclining chairs with stains.

Room # 112 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt and a plastic toilet paper holder with a white film coating the surface.

Room # 113 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt and a plastic toilet paper holder with a white film coating the surface.

Room # 117 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt and a plastic toilet paper holder with a white film coating the surface.

Room #118 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt.

Room # 119 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the sink fixtures with white/green lime type deposits and the room contained a non-cleanable cloth-covered chair.

Room #120 observed on 8/6/2015 between 12:00 and 1:00 PM revealed the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt and a plastic toilet paper holder with a white film coating the surface.

Room #122 observed on 8/6/2015 between 12:00 and 1:00 PM revealed a reclining chair with a tear in the right and left armrests and dirty footrest.


Administrative staff Z interviewed 8/5/2015 at 3:00 PM acknowledged the toilet and sink fixtures with white/green lime type deposits, a ceiling mounted vent with obvious dirt and a plastic toilet paper holder with a white film coating the surface in the bathrooms. Staff Z revealed they are starting to remodel but has no written action plan as of yet.

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation, lack of policies to review, and interview the Critical Access Hospital (CAH) failed to ensure the hospital was clean and orderly in one of two emergency supply carts. This deficient practice had the potential to affect the health of all current and future patients of the CAH.


Findings include:


-Emergency supply cart observed 8/3/15 at 1:25pm revealed a Zoll defibrillator (machine used to start the heart) visible dust on machine, and three open oxygen tubing adapters taped to the side of the cart with visible dust.
Licensed Practical Nurse staff F interviewed on 8/3/15 at 1:35pm acknowledged dust on Zoll defibrillator and adapters.
Policy review on 8/6/2015 revealed the CAH failed to develop a policy to ensure the emergency supplies and equipment was cleaned and ready for use.

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the hospital provided proper ventilation for patients requiring airborne precautions in one of one isolation rooms. This deficient practice had the potential to affect the health of all current and future patients of the CAH.


Findings include:


Policy titled "Tuberculosis Exposure Control Plan" reviewed on 8/5/2015 11:30 AM directed "... Place patient with suspected TB in Airborne Precautions in a negative pressure room ..."


Room #122 observed on 8/3/2015 at 10:30 AM revealed an isolation room with no working negative pressure ventilation.


Registered Nurse staff M interviewed on 8/5/2015 at 11:10 AM revealed that the negative pressure no longer works and they now use a High Efficiency Particulate Air (HEPA) Filtration System(a filter used to eliminate particles from the air).

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the governing body established policies to ensure patients receive care in a safe environment in thirteen of thirteen patient rooms and three of three hallways. This deficient practice has the potential to affect the health and safety of all suicidal patients admitted to the CAH.

Findings include:

Ligature risks were identified in the following patient rooms and hallways:


Room #102- removable ceiling tiles, shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, one bedside table with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, and pipe of toilet 32" length.

Room #103- removable ceiling tiles, shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, one bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, bathroom attached basket on wall 24" length, and pipe of toilet 32" length.

Room #104- removable ceiling tiles ,shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, one bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, bathroom attached basket on wall 24" length, and pipe of toilet 32" length.

Room #105- removable ceiling tiles, shelf on wall 25" length, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, two bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5 " length, sink 20" length, glass mirror 25" length, faucet 14" length, bathroom attached basket on wall 24" length, and pipe of toilet 32" length.

Room #106- removable ceiling tiles, shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, two bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, bathroom attached basket on wall 24" length, and pipe of toilet 32" length.

Room #107- removable ceiling tiles, shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, two bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, and pipe of toilet 32" length.

Room #108- removable ceiling tiles, shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, two bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, bathroom attached basket on wall 24" length, and pipe of toilet 32" length.

Room #112- removable ceiling tiles, shelf on wall 25" length, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, two bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, bathroom attached basket on wall 24" length, and pipe of toilet 32" length.

Room #113- removable ceiling tiles, shelf on wall 25" length, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, two bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, bathroom attached basket on wall 24" length, and pipe of toilet 32" length.

Room #117- removable ceiling tiles, shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, two bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, bathroom with two attached baskets on wall 9" length, and pipe of toilet 32" length.

Room #118- removable ceiling tiles, shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, two bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, bathroom with two attached baskets on wall 9" length, support handle on wall next to toilet 56" length and pipe of toilet 32" length.

Room #119- removable ceiling tiles, shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, one bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25 " length, faucet 14 " length, bathroom with two attached baskets on wall 9" length, and pipe of toilet 32" length.

Room #120- removable ceiling tiles, shelf on wall 25" length, corkboard 18" length x 24.5 width, closet two c-handles 4" length, two TV electric cords two 48" length, two above bed light fixture cords 36" length, one bedside tables with three c-handles 4" length, window blind with cord 48" length, one chain on entrance door 24" length, one round handle on bathroom door, one hook on inside of bathroom door, one sharp container 9.5" length, pipe on sink 19.5" length, sink 20" length, glass mirror 25" length, faucet 14" length, and pipe of toilet 32" length.

-South Medical Surgical hallway observed 8/5/14 between 1:15pm and 2:00pm revealed the following possible ligature risks:
1. Two of two handrails measured 176" .
2. One of one handrail measured 39" .
3. One of one handrail measured 83" .
4. One of one handrail measured 42 ½" .
5. One of one handrail measured 14" .
6. One of one handrail measured 22" .
7. One of one handrail measured 88" .
8. One of one handrail measured 27 ½" .
9. One of one handrail measured 54" .
10. One of one handrail measured 144" .
11. Fire doors with two C handles and two hydraulic hinges.

-West cardiac rehab hallway observed 8/4/15 between 1:15pm and 2:00pm revealed the following possible ligature risks:
1. One of one handrail measured 196 ½"
2. One of one handrail measured 174 ½" .
3. One of one handrail measured 191 ½" .

-North Medical surgical hallway observed 8/4/15 between 1:15pm and 2:00pm revealed the following possible ligature risks:
1. Two fire doors with two C handles and two hydraulic hinges.
2. Six of six C handles on cabinets along south wall of north medical surgical hallway.
3. One of one handrail measured 177 ½" .
4. One of one handrail measured 106" .
5. One of one handrail measured 176" .
6. One of one handrail measured 142" .
7. One of one handrail measured 54" .
8. One of one handrail measured 28" .
9. One of one handrail measured 38 ½"
10. One of one handrail measured 60" .
11. One of one handrail measured 82" .


Registered Nurse staff P interviewed 8/5/2015 at 8:45 AM indicated that all patients who are diagnosed with suicidal thoughts or attempts are kept on a 1:1 observation and their room is nearest to the nurses station. Staff P reported emergency department patients are 1:1 also and transferred to an appropriate behavioral health facility as soon as possible.

Registered Nurse staff A interviewed 8/5/2015 at 11:00 AM acknowledged there is not a written policy to ensure all patients with suicidal thoughts or attempts are placed on a 1:1 observation status.

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation, document review, staff interview the CAH failed to ensure that outdated, mislabeled or otherwise unusable drugs are not available for patient use in two of two emergency supply carts, one of one pharmacy areas, three of three medication storage cabinets. The CAH failed to have a policy for labeling of medications.


Findings include:


- Pharmacy observed on 8/3/2015 at 11:30 AM revealed the following medications open and undated:

1) One of three bottles of Milk of Magnesia (a medication to reduce stomach acid), one of five bottles of MI-Acid (a medication to reduce stomach acid).

2) One of three bottles of Bismatrol (medication used to treat stomach discomforts).

3) One of one bottles of Ferrous Sulfate Elixir (Iron supplement).

4) One of one bottles of Prednisolone Sodium Phosphate (medication used to treat allergic reactions).

5) One of one bottles of Donnatal Elixir (medication used to treat irritable bowel syndrome).

6) One of one bottles of Sodium Polystyrene Sulfate (a medication used to treat high levels of potassium in the body).

7) One of one bottles of Nystatin oral suspension (a medication used to treat infections of the mouth).

8) One of one bottles of Acetaminophen and Codeine Phosphate (a medication to relieve mild to moderate pain) with an open and dated 6/2/2013.


Registered Nurse staff A interviewed on 8/3/2015 at 11:40 AM acknowledged the medications located on the pharmacy shelf were open and undated. Staff A stated, "All medications that are multi-use should have the date they were opened marked on them and should be discarded after 30days".

Registered Nurse staff J interviewed 8/4/2015 at 1:35 PM revealed they have or had letters from the manufacturers of some of the oral medications that directed them to dispose of the open and unused oral medications according to the expiration date on the bottle. Staff J acknowledged that they could not produce this documentation at this time.

Policy review dated 8/3/2015 at 12:00 PM revealed the CAH failed to develop a policy to ensure all medications were labeled with the date they were opened and disposed of in accordance with the manufacturer's suggested BUD (beyond use date).

- Policy titled "Medication Policy" reviewed 8/3/2015 at 3:30 PM directed staff "...Medicines and drugs will be regularly and carefully check for expiration dates and never used beyond the date of expiration. Upon the date of expiration they will be removed from the shelf and either returned to the company or destroyed under the authority of the pharmacist in charge or pharmacy RN ..."


- Emergency cart located in the Trauma room observed on 8/3/2015 at 12:20 PM revealed the following outdated medications:


1) One of one Epi-Pen Auto injector (medication used to treat allergic reactions) with an expiration date 7/2015.


2) One of seven 10ml (milliliter) syringes of Sodium Chloride (medication used to increase fluids in the body) with an expiration date of 7/2015.


Registered Nurse staff A interviewed on 8/3/2015 at 12:25 PM acknowledged the expired medications.


- Locked cabinet located in the Trauma room observed on 8/3/2015 at 12:30 PM revealed one of two bottles of Nitroglycerine (medication used to treat high blood pressure) opened 6/16/2015 with a written discard date of 9/16/2015.


Registered Nurse staff A interviewed on 8/3/2015 at 12:30 PM acknowledged the medication had been opened and available for use beyond 30 days.


- Glass cabinet located in the Trauma room observed on 8/3/2015 at 12:35 PM revealed the following out dated medications:


1) One of three 1000ml bags of Lactated ringers (medication used to replace electrolytes in the body) with an expiration date of 8/1/2015


2) Two of seven 1500ml bottles of Sodium Chloride (medication used to replace fluids in the body) with an expiration date of 8/1/2015.


Registered Nurse staff A interviewed on 8/3/2015 at 12:40 PM acknowledged the expired medications located in the Trauma rooms glass cabinet.



- Emergency supply cart located at the nurses station observed on 8/3/15 at 1:25pm revealed the following outdated medications:

1. Six of six Atropine Sulfate 1mg with an outdate of 6/1/2015.

2. Two of two Dexamethasone 1ml vial with an outdate of 7/2015.

3. Five of five Epinephrine 1ml vial with an outdate of 6/1/2015.

4. One of one Diazepam 5mg/ml with an outdate of 8/1/2015.

5. One of four Solu Medrol 2ml with an outdate of 6/2015.

6. One of one Nitroglycerine 25mg/250ml with an outdate of 5/2015.

7. One of one Dopamine 800mg/250ml with an outdate of 8/2011.

8. One of one Lidocaine 2grams/500ml with an outdate of 6/2015.

9. One of one pediatric Epinephrine 1:10,000 with an outdate of 6/15.

- Nursing Department monthly assignment sheet observed 8/4/15 revealed crash cart not checked for outdates as required for the month of July 2015.

Registered Nurse staff A and Licensed Practical Nurse (LPN) staff F interviewed on 8/3/15 at 1:35pm acknowledge outdated medications.

- Locked cabinet located in the radiology department observed on 8/3/15 between 10:20-10:37am revealed twenty packets of E-Z gas antacid (medication to help with upset stomach) with an expiration date of 10/13.

Radiology Staff I interviewed on 8/3/15 at 10:37am acknowledged outdated medications.

-Empty bottle storage closet K located in the emergency department observed on 8/5/2015 between 2:15pm-2:30 PM revealed one unsecured bottle of carbon dioxide (gas released when people breathe) with an expiration date of 3/2006.

Registered Nurse staff A interviewed on 8/5/2015 at 2:30 PM acknowledged outdated bottle of carbon dioxide.

The Critical Access Hospital (CAH) reported a census of three patients. Based on document review and interview the Critical Access Hospital (CAH) failed to ensure the medical records director is a registered record administrator or an accredited record technician as certified by the American Health Information Management Association, or who meets the educational or training requirements for such certification.


Findings include:

Job description titled "HIM Department Head" reviewed on 8/6/2015 at 8:45 AM directed "... Must possess a current license as Registered Health Information Technician (RHIT) or exam eligible, or a Registered Health Information Administrator (RHIA) or exam eligible ..."

Medical record staff N interviewed 8/6/2015 at 2:45 PM indicated they had no formal training as a Heath Information Manager and is not currently licensed or certified as a (RHIT) or (RHIA).

The Critical Access Hospital (CAH) reported a census of three patients. Based on policy review, medical record review, and staff interview, the CAH failed to ensure medical records completion no later than 30 days after discharging a patient for 1 of 20 medical records reviewed (medical record # 11).

Findings include:

- Policy titled "Incomplete Medical Records on 8/6/15 at 8:30am directed to "...The medical record should be complete no later than 30 days after discharge ..." .

- Medical record #11 reviewed on 8/4/15 at 1:30pm lacked evidence of a physician's signature on the History and Physical on 6/24/15, Emergency Room Physician notes on 6/24/15, Physician Orders on 6/24/15, Progress note on 6/25/15, and discharge summary on 6/26/15.

Medical Record Staff G interviewed on 8/5/15 at 3:20pm acknowledged the medical record was not complete within the 30 days of discharging a patient.

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation and staff interview, the CAH failed to safeguard confidential patient information from possible destruction. This deficient practice has the potential to affect patients' records in one of one cardboard boxes and 28 of 28 loose charts.

Findings include:

- The Medical Records storage room observed on 8/3/15 at 3:17pm revealed one Bankers box (cardboard boxes used to store medical records) and 28 charts in manila folders placed directly on the floor.

Medical Records Staff G interviewed on 8/3/15 at 3:17pm acknowledged the box contained patients' medical records and sat directly on the floor with the potential for flooding.

Policies reviewed on 8/6/2015 at 10:00 AM revealed the CAH failed to develop a policy to ensure the protection of medical records from destruction.

The Critical Access Hospital (CAH) reported a census of three patients.Based on document review and staff interview the Critical Access Hospital (CAH) failed to ensure Advanced Directive instructions were appropriately documented for three of four swing bed records reviewed (patient#'s 20, 21 and 22). This deficient practice had the potential to affect all current and future swing bed patients of the CAH.

Findings included:

-Policy titled "Advanced Directives" reveals "...there shall be documented in the individual's medical record whether the individual has executed any advance directives ..."

- Paitnet #20, 21, and 22's medical records reviewed on 8/4/2015 revealed the records lacked evidence that advanced directive education was completed on the patients' charts.

Unit Clerk staff Y interviewed on 8/4/2015 at 3:00 PM verified patients #20, #21 and #22 records lacked evidence of advanced directive education.

The Critical Access Hospital (CAH) reports a daily census of three patients. Based on document review and interview the Critical Access Hospital (CAH) failed to provide appropriate activities and failed to assess the patient's activity needs and plan appropriate interventions in the plan of care for one of four swing bed sampled records reviewed (patient # 19). The CAH failed to have a qualified Activities Director. This deficient practice had the potential to affect all current and future swing bed patients of the CAH.

Findings included:

Policy title "Swing Bed Policies and Procedures Activity Program" reviewed on 8/5/2015 reveals "...it is the responsibility of the Activities Director, Swing Bed coordinator and/or Designee ...activities assessment will be completed within five days after admission ..."

- Record review on 8/4/2015 on patient #19 revealed the record lacked evidence of an activity program focused on promoting and enhancing the quality of each resident's life. The patient's care plan lacked information to direct the patient's activity program.

Administrative Staff RN E interviewed on 8/3/15 at 3:10pm verified patient #19's record lacked evidence of an ongoing activity program and that there were no ongoing activities program available. She further stated that the swing bed program currently lacks an activities director.

The Critical Access Hospital (CAH) reports a daily census of three patients, two acute and one skilled swing bed patient. Based on record review and staff interview the Critical Access Hospital failed to provide for the social services needs for one of four swing bed sampled records (patient #22). The CAH failed to have a qualified social work designee. This deficient practice had the potential to affect all current and future swing bed patients of the CAH.

Findings included:

- Record review on 8/4/2015 on patient #22 revealed the record lacked evidence of a social service assessment focused on the psychosocial needs of the patient. The patient's care plan failed to document social service interventions.

Registered Nurse Staff E interviewed on 8/3/2015 at 3:10 PM verified patients #22 records lacked evidence of social service interventions and the swing bed program lacks current social services designee or activities director.