HospitalInspections.org

Based on review of policies, patient medical records, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation (rehab) services for swing bed patients. Problem identified with 5 of 5 open swing bed patient medical records and 5 of 5 closed swing bed patient medical records. (Patients #1, Patient #2, Patient #3, Patient #4, and Patient #5) The CAH staff identified an average monthly census of 177 in the fiscal year of July 2021 to June 2022.

Failure to ensure a physician ordered specialized rehab services could result in swing bed patients not receiving specialized rehab services appropriate to their medical condition.

Findings include:

1. Review of CAH policy titled "Skilled Care (Swing Bed) Services", effective 5/2022, revealed in part ". . . Physical, Occupational and Speech Therapy services are provided as ordered by a physician or provider."

2. Review of Patient #1's closed medical record revealed Patient #1 was admitted for swing bed services on 7/25/2022 at 16:26 PM for swing bed services with diagnosis of history of hypertension, diabetes, hyperlipidemia, chronic kidney disease, aortic valve replacement, virtuous hemorrhage with retinal detachment, morbid obesity and obstructive sleep apnea. Patient recently had a hospital stay following a diagnosis of severe sepsis secondary to bacteremia. Patient #1 was admitted to inpatient swing for continued intravenous (IV) therapy and strengthening due to physical deconditioning

An electronic order placed in Patient #1's medical record dated 7/25/2022 at 6:03 PM, revealed Practitioner A, Advanced Nurse Practitioner (ARNP) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.

3. Review of Patient #2's closed medical record revealed Patient #2 was admitted for swing bed services on 6/28/2022 at 5:29 PM for swing bed services after undergoing a bilateral lower extremity below the knee amputations. Patient needed physical and occupational therapy due to amputations.

An electronic order placed in Patient #2's medical record dated 6/28/2022 at 3:28 PM, revealed Practitioner A, Advanced Nurse Practitioner (ARNP) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.

4. Review of Patient #3's open medical record revealed Patient #3 was admitted for swing bed services on 8/24/2022 at 1:57 PM for swing bed services with diagnosis of recent seizures with a history of a cerebral vascular accident (CVA) and atrial fibrillation. Patient #3 has weakness due to recent surgery to left wrist and chronic pain. Patient needed physical and occupational therapy for strengthening for home safety.

An electronic order placed in Patient #3's medical record dated 6/28/2022 at 3:28 PM, revealed Practitioner A, Advanced Nurse Practitioner (ARNP) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.
5. Review of Patient #4's open medical record revealed Patient #4 was admitted for swing bed services on 4/22/2022 at 2:27 PM for swing bed services with diagnosis of history of a pelvic abscess status post drain placement, chronic congestive heart failure, morbid obesity, restrictive lung disease, diabetes, and chronic kidney disease. Patient has had increased weakness due to increased cardiac failure, requiring IV therapy and wound management. Patient needed physical and occupational therapy for strengthening and difficulty moving.

An electronic order placed in Patient #4's medical record dated 4/22/2022 at 4:26 PM, revealed Practitioner A, Advanced Nurse Practitioner (ARNP) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.


6. Review of Patient #5's open medical record revealed Patient #5 was admitted for swing bed services on 4/26/2022 at 2:32 PM for swing bed services after undergoing a recent surgery for an incarcerated umbilical hernia requiring a wound vacuum decreasing mobility. The patient needed physical and occupational therapy for transfers and activities of daily living.

An electronic order placed in Patient #5's medical record dated 4/26/2022 at 4:01 PM, revealed Practitioner A, Advanced Nurse Practitioner (ARNP) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.

7. During an interview on 9/15/2022 at 10:04 AM, Staff B, Nursing Manager, acknowledged a mid-level provider ordered specialized rehabilitation (rehab) services for swing bed patients and not a physician for skilled Patients #1, Patient #2, Patient #3, Patient #4, and Patient #5.

8. During an interview on 9/15/2022 at 9:4 AM, Staff A, ARNP, confirmed the mid-level provider wrote orders to admit patients to swing bed including physical, occupational, and speech therapy.

9. During an interview on 9/15/2022 at 10:10 AM, Chief Nursing Officer (CNO), acknowledged the lack of a policy to address a physician needs to write the orders for specialized rehabilitation (rehab) services for swing bed patients and not a mid-level provider.