HospitalInspections.org

On the days of the Recertification Survey based on observation, interview, and facility record review, the Critical Access Hospital failed to ensure that pediatric emergency equipment was provided in the Radiology Department.

The findings are:

On 01/06/10 at 1115, a tour was conducted with the Director of Radiology. Observation of the Drug box and emergency equipment revealed 1 pediatric small airway. An adult Ambu bag and several adult airways of different sizes were observed next to the emergency box. No pediatric Ambu bags or other pediatric airways of different sizes were present. The findings were confirmed with the Director who verified that all age pediatric patients are treated in the Radiology Department. There was not a hospital policy regarding pediatric Ambu bags/airways on the emergency equipment list for the Radiology Department.

On the days of the Recertification Survey based on policy review and staff interview, the Critical Access Hospital (CAH) was not able to provide documentation of clearly distinguishable criteria for admission to and discharge from the Observation Service.

The findings are:

On 1/6/2010 at 1400, review of the CAH Policy and Procedures Manual failed provide documentation of specific policies and procedures for admission to and discharge from the Observation Service which were clearly distinguishable from those used for inpatient admission and discharge. On 1/6/2010 at 1500, an interview with the Director of Utilization Review and Program Improvement verified there were no policies and procedures for admission to and discharge from Observation Services .

On the days of the Recertification survey based on observations and interview, the facility failed to ensure a preventive maintenance program for the availability of medical supplies for patients.

The findings included:

On 1/5/10 at 1030, observation revealed one (1) lumbar puncture tray with an expiration date of 9/2009 and two pediatric/infant lumbar puncture trays with an expiration date of 11/2008 in the medical supply room on the nursing unit. The findings were reviewed and confirmed with RN # 2 on 1/5/10 at 1030..

On the day of the Recertification Survey based on observation and staff interview, the Critical Access Hospital Emergency Department (ED) failed to ensure that staff drinking cups were properly stored.

The findings are:

On 1/5/2010 at 1055, observations during a tour of the ED dirty utility room revealed nineteen (19) drinking cups observed in the dirty sink area. Four drinking mugs were hanging from hooks above the sink, eight mugs were placed on a white towel in the splash area of the sink, and the rest were against the wall. A pair of surgical scissors and a curved hemostat was lying in the bottom of the dirty sink. The ED Department Director verified the findings on 1/5/10 at 1100. The Department Director reported drinking cups and mugs were washed in the dirty utility room sink, and then stored in the area by the sink in the dirty utility room after use by staff.

On the days of the Recertification Survey based on interview, record review, and hospital policy review, the facility failed to ensure that the physician reviewed and signed the medical records of patients cared for by Nurse Practitioners and Physician Assistants for 1 of 12 closed records reviewed. (Patient #16)
The findings include:
A medical record review conducted on 1/6/10 at 1500 revealed Patient #16 with an admission date of 7/6/09 and a discharge date of 7/8/09 had the following diagnoses: Chest Pain (CP), Shortness of Breath (SOB), and History (HX) of HTN (Hypertension). The discharge summary, history and physical, and physician progress notes were not dated and/or timed by the physician. The H&P and progress notes written by the Physician Assistant (PA) were not countersigned by the physician.
The MEDICAL STAFF RULES & REGULATIONS reviewed and revised April 2006, states, " ...Medical Records ...4. The attending physician must counter sign any reports recorded by his/her Physician Assistant, Nurse Practitioner, or Resident directly under his/her supervision ... " . The findings were verified by the Director Professional Services on 1/6/10 at 1630.

On the day of the Recertification Survey based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that health care services were consistent with appropriate CAH written policy.

The findings are:

On 1/6/2010 at 1300, a review of Observation Service (closed medical record) of Patient #9 revealed incomplete documentation of medication administration. On 12/17/2009, the physician ordered Nitropaste 1 inch to the patient's chest wall every 8 hours. The nurse administering the medication failed to document the 0630 dose of the Nitropaste on the Medication Administration Record (MAR) or in the nurse progress notes. The CAH Policy MM.4.10, Subject: Medication Procedure, Item #11, reads, "Recording of medication administered will be charted on the MAR (Medex) immediately after giving medication to each patient". The
finding was verified by Director of Professional Services on 1/6/2010 at 1515.

On the days of the Recertification Survey based on record review, and review of hospital policies and procedures, and interview, it was determined that there was no facility policy that included a description of the services offered directly, or those services provided through agreement or arrangement.

The findings are:

During hospital policy review on January 6, 2010 at 0900, it was noted that there were no organizational policies that outlined which facility services were offered directly versus services provided via
agreements or contract. In an interview with the Chief Executive Officer on 1/6/10 at 1500,
this information was confirmed. There was no facility policy found that required a delineation
of services offered directly from those provided indirectly.

On the days of the Recertification Survey based on observation, interview, and facility record review, the Critical Access Hospital failed to ensure that expired drugs and biologicals were removed from 2 of 5 patient treatment areas.(Surgery Suite and Emergency Room)

The findings are:

On 01/05/10 at 1000, a tour was conducted with the Operating Room Supervisor. Observation of the anesthesia cart in the operating room revealed 2 one cubic centimeter(cc) ampules of 1:1000 Epinephrine that had a expiration date of December 2009, and an ampule of Ephedrine 50 milligram (mg) / cc with a expiration date of 10/07. Observation of the medication room revealed 3 cannisters of Soda Sorb with an expiration date of 9/09. The findings were confirmed with the Operating Room Supervisor who explained that all drugs are checked for expiration by pharmacy monthly.

Review of facility pharmacy policy and procedure, titled, Inventory, reads, " Procedure: All dated drugs in all storage ares and medication centers in the hospital are checked during the first or last week of month for expiration dates...''






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On January 5, 2010 at 1030, a ten milliliter (ml) vial of Sterile Water was observed to have an expiration date of 1/1/2010. The finding was verified by ED Registered Nurse (RN) #1. Observation on 1/5/2010 at 1045 revealed three (3) packages containing twenty Short Term Oral Swab Systems that had an expiration date of 2/2009. The finding was verified by ED RN #1 at 1045 on 1/5/10. Observation in ED Examination Room #5 on 1/5/2010 at 1050 showed a sterile culture tube that had an expiration date of 12/11/2009. The finding was verified by ED RN #1.

Observation of a double locked narcotics box in the ED on 1/5/10 at 1115 revealed three (3) containers of Acetaminophen with codeine five milliliters (ml) that had discoloration on the foil lids caused by one container leaking onto others. One of the three (3) containers had a crumbly substance rubbing off the lid when touched. ED RN #1 and the Pharmacist were unable to ensure the integrity of container seals. Twelve (12) syringes of Diazepam injectable two (2) ml (five milligrams (mg) per ml) had an expiration date of 9/2009. One syringe of Diazepam injectable 2 ml (five mg/ml) had expiration an date of 12/2009. Three (3) syringes of Demerol injectable 100 mg per ml had expiration date of 8/2009. Lorazepam tablet 1 mg had an expiration date of 12/2009. The findings were verified by ED RN #1 and Pharmacist on 1/5/10 at 1115.

On 1/5/2010 at 1130 observation of medication cart found one (1) Furosemide 40 mg/4 ml vial with a needleless syringe plunged into a rubber stopper lying in the drawer of the medication cart. The vial had no open date or staff initials on the label. The finding was verified by ED RN #1 on 1/5/10 at 1130. One (1) 2 ml vial of Sodium Chloride 0.9% with a needleless syringe plunged into rubber opening was found lying in a drawer in the medication cart. The vial had no open date or staff initials on the label. The finding was verified by ED RN #1 on 1/5/10 at 1130. A plastic box of Amoxicillin 500 mg tablets had no expiration date on the label.
Two bags of Heparin 25000 Units (U) in 250 ml of 0.45% Sodium Chloride Solution had an expiration date of 12/2/2009. One (1) 50 ml vial of Marcaine .25% had an expiration date of 10/2009. Five vials of Vitamin K 10 mg/ml had an expiration date of 11/1/2009. Three vials of Nitropress 50 mg/2 ml had an expiration date of 10/2009. Two syringes of Heparin 5000 U/ml had an expiration date of 11/2009. One vial of Protamine Sulfate 250 mg/25 ml had an expiration date of 10/2009. Two vials of Amidate 20 mg/10 ml had an expiration date of 12/1/2009. The findings were verified by ED RN #1 on 1/5/10 at 1130.

On 1/5/2010 at 1150, observation of refrigerated drugs found one Promethazine suppository had an expiration date of 11/2009. The
finding was verified by ED RN #1 on 1/5/10 at 1150.

In an interview on 1/5/2010 at 1145, the Pharmacist stated that he/she is responsible for doing monthly checks of all medications in Emergency Department and removal of all expired medications.

On 1/5/2010 at 1300, the review of the Emergency Department Policy and Procedure Manual,reviewed and revised on 1/5/2010, reads, "Subject: Use of Multidose vials and Medication Containers. Procedure: #4 After opening, multi-dose vials are to be labeled with the date, time, and initials; # 8.A pharmacist will conduct monthly inspections and recall any outdated floor stock and medications."

On the days of the Recertification Survey based on record review, review of hospital policies and procedures, and interview, the facility failed to ensure that facility policies were reviewed at least annually by a group of professional personnel.

The findings are:

Review of the hospital policy and procedure manuals and other data on January 6, 2010 revealed that the Nursing Policy and Procedure Manual was last reviewed and signed on October 15, 2008, and that the Medical Staff Bylaws, Rules and Regulations were last signed as reviewed on April 2006. The information was confirmed during an interview with the Chief Executive Officer on January 6, 2010 at 1500.

On the days of the Recertification Survey based on record review, review of hospital contacts, and interview, the facility failed to ensure that a list of all services furnished under arrangement or agreements was available.

The findings are:

During a review of the hospital contracted services on January 6, 2010 at 1000, it was noted that there was no list of contracts or services provided by the facility available. In an interview with the CEO (Chief Executive Officer) on January 6, 2010 at 1500, the CEO confirmed that the hospital had no list of contracted services, and there was no facility policy or procedure that required list of contracted services be developed.

On the days of the Recertification survey based on interview, record reviews, and review of policy and procedure, the facility failed to ensure that nursing services met the needs of its patients for four of six resident medical records reviewed (Residents #1, 3, 4, and 5).

The findings included:

On 1/5/10 at 1430, a review of Resident #1's open medical record revealed the fifty-one year old was admitted on 12/17/09 with diagnoses of Status post Encephalitis, Deep Vein Thromboses, Bilateral Pneumothorax and Pneumonia. needs. Review of the patient's chart showed the nutritional screening score was zero on the initial nursing assessment form. The screening questions included the clinical parameter for nutritional supplement which would rate a score of six. The initial physician orders on 12/17/09 included Ensure twice daily. The supplement was not documented in the nutritional screening score. A score of six or more would be considered at risk and a referral for a nutritional assessment by dietary should have been completed. There was no documentation of a nutrition assessment by dietary. Documentation on the graphic sheet on 1/1/10 noted the patient ate 35% at lunch and supper; 1/2/10- 30% of breakfast, 5% lunch, and 25% supper; and 1/3/10- 50% breakfast, lunch and supper. The patient's hemoglobin on 1/3/10 was 9.5 g/dL; 9.1 g/dL on 1/4/10; and 8.8 g/dL on 1/5/10. The patient's height was 5'6" and weight was 130 pounds. There was still no documentation of a nutrition referral or consult.

On 1/5/10 at 1215, a review of Resident #3's open medical record revealed the eighty-two year old was admitted on 1/1/10 with diagnoses of Anemia, generalized weakness, recent Upper GI (Gastrointestinal) bleed, Hypertension and Parkinson's disease following an acute inpatient hospitalization. The initial nursing assessment completed on 1/1/10 failed to assess the educational needs of the patient. The "Initial Assessment/Teaching" section on the Interdisciplinary Patient and Family Education Record was not completed upon admission to identify the patient and family education needs . The Director of Patient Care Services reported in an interview on 1/6/10 at 1400 that an initial assessment of the educational/teaching needs of the patient should be completed upon admission.

On 1/5/10 at 1415, a review of Resident #4's open medical record revealed the eighty-nine year old was admitted on 1/1/10 due to weakness following an acute hospitalization for Congestive Heart Failure, Cardiomyopathy, Hypertension, and Diabetes Mellitus. The "Initial Assessment/Teaching" section on the Interdisciplinary Patient and Family Education Record was not completed upon admission to identify the patient and family educational needs. The Director of Patient Care Services reported in an interview on 1/6/10 at 1400 that an initial assessment of the educational/teaching needs of the patient should be completed upon admission.

On 1/6/10 at at 1050, a review of Resident #5's closed medical record revealed the eighty-seven year old was admitted on 11/27/09 with diagnoses of weakness, Anemia, and Hypotension following an acute care hospitalization for severe Dehydration, Hypotension and Anemia. The "Initial Assessment/Teaching" section on the Interdisciplinary Patient and Family Education Record was not completed upon admission to identify the patient and family educational needs. The Director of Patient Care Services stated in an interview on 1/6/10 at 1400 that an initial assessment of the educational/teaching needs of the patient should be completed upon admission.

Review of hospital Policy, "Patient/ Family Education", read, "Objective: To ensure the patient and/or when appropriate, his/her significant other(s) are provided with education that can enhance their knowledge, skill, and those behaviors necessary to fully benefit from the health care interventions provided ... Procedure: 1. Patient's educational needs pertaining to self-care will be assessed, identified and addressed ... "

Review of hospital Policy, revised 9/03, read, " ... Standard 2: Nursing care of patients at Edgefield County Hospital is the primary responsibility of the Nursing Department. Implementation: Authority for determining the quantity and quality of nursing care services rendered to patients is assigned to the nursing staff, who give priorities to the needs of patients. Safe and competent nursing care is available at all time. Nursing Administration if responsible for establishing policies and procedures which enable employment of adequate personnel to provide this service. ...Standard 4: The purpose of the Nursing Department is to plan, implement, and evaluate innovative patient care programs that include safe, competent clinical nursing practice. Implementation: Interdepartmental care plans are maintained on all patients....Collaboration with the physician, dietician, physical therapist, pharmacist, and other allied health workers is necessary for development of comprehensive and beneficial care plans. It is imperative that the plan of care be communicated effectively to all direct care givers on all shifts, whether in writing, verbally, or through patient care conferences..."

Review of hospital Policy, "Charting, Documentation of Nursing Care Rendered", read, "The patient's record is the most important assessment tool available to provide continuity of care on a twenty-four (24) hour basis. It is the nursing personnel's only proof of the nursing care rendered.... At Edgefield County Hospital, all patient care will be documented in the form of a systems assessment at the beginning of each shift and noes throughout the shift ... "

Review of hospital Policy, "Nurse's Role in Discharge Planning Process", read, "... 2. All patients are to be assessed upon admission (to include, but not limited to, functional ability, nutritional status) with ongoing re-assessment for discharge planning needs..."

On the days of the Recertification Survey based on interview, record review, and hospital policy review, the facility failed to ensure a Registered Nurse supervised and evaluated nursing assessments conducted by a Licensed Practical Nurse for 5 of 12 closed records reviewed. (Patient #16, 17, 18, 23, and 25)
The findings include:
A medical record review conducted on 1/6/10 at 1500 revealed Patient #16 with an admission date of 7/6/09 and a discharge date of 7/8/09 had the following diagnoses: Chest Pain (CP), Shortness of Breath (SOB), and History (HX) of HTN (Hypertension). The Nursing Admission Assessment Record dated 7/6/09 that was completed by the Licensed Practical Nurse (LPN) did not show documentation of being reviewed or countersigned by a Registered Nurse (RN).
A medical record review conducted on 1/6/10 at 1405 revealed Patient #17 with an admission date of 7/4/09 and a discharge date of 7/9/09 had a diagnosis of Intractable Vomiting. The Nursing Admission Assessment Record dated 7/4/09 that was completed by the LPN did not show documentation of being reviewed and/or countersigned by a RN.
A medical record review conducted on 1/6/10 at 1430 revealed Patient #18 with an admission date of 12/7/09 and a discharge dated of 12/11/09 had the diagnosis of Bronchitis with Hypoxia. The Nursing Admission Assessment Record dated 12/7/09 that was completed by the LPN did not show documentation of being reviewed and/or countersigned by a RN.
A medical record review conducted on 1/5/10 at1500 revealed Patient #23 with an admission date of 10/30/09 and a discharge date of 11/1/09 had the diagnosis of Left Arm Cellulitis. The Nursing Admission Assessment Record dated 10/30/09 that was completed by the LPN did not show documentation of being reviewed and/or countersigned by the RN.
A medical record review conducted on 1/6/10 at 0945 revealed Patient #25 with an admission date of 7/29/09 and a discharge date of 7/31/09 had the diagnoses of Dehydration, Nausea, and Vomiting. The Nursing Admission Assessment Record dated 7/29/09 that was conducted by the LPN did not show documentation of being reviewed and/or countersigned by the RN. The findings were verified by the Director of Professional Services on 1/6/10 at 1630.

On the days of the Recertification survey based on interview, record reviews, and review of hospital policy and procedure, the facility failed to ensure that the clinical records system was maintained in accordance with written polices and procedures for 3 of 11 open medical records (Resident #2, 3, and 4) reviewed for care and services and 2 of 20 closed medical records reviewed for care and services. (Residents #5 and 6)

The findings included:

On 1/5/10 at 1115, a review of Resident #2's open medical record revealed the eighty-five year old was admitted on 1/2/10 following an acute inpatient hospitalization due to Pneumonia, Congestive Heart Failure, Diabetes Mellitus and Hypertension. There was no documentation of an admission history and physical by the physician in the resident's record upon admission to the swing bed unit. The patient's valuables form was not signed by the resident upon admission to the swing bed unit. The form contained a hand written note which read, "See previous sheet please.". In an interview on 1/6/10 at 1445, the Director of Patient Care Services reviewed the finding, and reported that the form referred to the valuables form during the patient's acute hospitalization.

On 1/5/10 at 1215, a review of Resident #3's open medical record revealed the eighty-two year old was admitted on 1/1/10 with diagnoses of Anemia, generalized weakness, recent upper GI (gastrointestinal) Bleed, Hypertension and Parkinson's disease following an acute inpatient hospitalization. Physician progress notes dated 1/2/10 and 1/?/10 did not include the time that the notes were written. A physician progress note written after the progress note dated 1/2/10 was not dated or timed.

On 1/5/10 at 1415, a review of Resident #4's open medical record revealed the eighty-nine year old was admitted on 1/1/10 due to weakness following an acute hospitalization for Congestive Heart Failure, Cardiomyopathy, Hypertension, and Diabetes Mellitus. There was no documentation of an admission history and physical by the physician in the resident's record upon admission to the swing bed unit.

On 1/6/10 at at 1050, a review of Resident #5's closed medical record revealed the eighty-seven year old admitted on 11/27/09 with diagnoses of weakness, Anemia, and Hypotension following an acute care hospitalization for severe Dehydration, Hypotension and Anemia. Physician orders upon admission dated 11/27/09 included physical therapy for strengthening and ambulation. An initial evaluation was completed by the physical therapist on 11/30/09. The plan of treatment was signed by the physician on 11/28/09 prior to the physical therapy evaluation.

On 1/6/10 at 1150, a review of Resident #6's closed medical record revealed the eighty-four year old was admitted on 10/15/09 with diagnoses of weakness, Depression, weight loss, and poor appetite. The physician progress note dated 10/23/09 did not include the time that the note was written. The physician progress notes dated 10/29 did not include the year or time that the note was written.

Review of hospital Policy, "Charting, Documentation of Nursing Care Rendered", read, "The patient's record is the most important assessment tool available to provide continuity of care on a twenty-four (24) hour basis. It is the nursing personnel's only proof of the nursing care rendered.... At Edgefield County Hospital, all patient care will be documented in the form of a systems assessment at the beginning of each shift and noes throughout the shift ... "

Review of the "Medical Staff Rules and Regulations", reviewed and revised April 2006, read, " .... Medical Records: 1. The attending physician will be responsible for the preparation of a complete and legible medical record for each patient, for each admission... 2. A complete history and physical, signed by the attending physician will be recorded within twenty-four (24) hours of admission ... 5. All entries in the patient's medical record will be accurately dated and authenticate...

On the days of the Recertification Survey based on interview, record review, and hospital policy review, the facility failed to ensure that all entries in the medical record were dated, timed, by the physician and mid-level practitioners (Physician Assistant and Nurse Practitioner) for 12 of 12 closed records reviewed. (Patient #14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25)
The findings include:
A medical record review conducted on 1/6/10 at 1535 revealed Patient #14 with an admission date of 8/17/09 and a discharge date of 8/25/09 had the following diagnoses: Infected Left Finger, Diabetes Mellitus Type II (DM), and Hypertension (HTN). The discharge summary, history and physical (H&P), physician consultation, and physician progress notes were not dated and/or timed by the physician.
A medical record review conducted on 1/6/10 at 1510 revealed Patient #15 with an admission date of 9/2/09 and a discharge date of 9/4/09 had the following diagnosis of Thrombocytopenia. The discharge summary and history and physical were not dated and/or timed by the physician.
A medical record review conducted on 1/6/10 at 1500 revealed Patient #16 with an admission date of 7/6/09 and a discharge date of 7/8/09 had the following diagnoses: Chest Pain (CP), Shortness of Breath (SOB), and History (HX) of HTN. The discharge summary, history and physical, and physician progress notes were not dated and/or timed by the physician.
A medical record review conducted on 1/6/10 at 1405 revealed Patient #17 with an admission date of 7/4/09 and a discharge date of 7/9/09 had a diagnosis of Intractable Vomiting. The discharge summary, history and physical, physician consultation, operative report, and physician progress notes were not dated and/or timed by the physician.
A medical record review conducted on 1/6/10 at 1430 revealed Patient #18 with an admission date of 12/7/09 and a discharge dated of 12/11/09 had the diagnosis of Bronchitis with Hypoxia. The H&P, physician orders, and physician progress notes were not dated and/or timed by the physician.
A medical record review conducted on 1/6/10 at 1130 revealed Patient #19 with an admission date of 6/28/09 and a discharge date of 7/1/09 had the diagnosis of Pancreatitis. The discharge summary, history and physical, physician orders, and physician progress notes were not dated and/or timed by the Nurse Practitioner (NP).
A medical record review conducted on 1/6/10 at 1030 revealed Patient #20 with an admission date of 7/15/09 and a discharge date of 7/18/09 had the diagnoses of Leukocytosis and Febrile Illness. The discharge summary, history and physical, and physician progress notes were not dated and/or timed by the physician. A telephone order taken on 7/15/09 was not signed, dated, and timed by the physician.
A medical record review conducted on 1/6/10 at 1115 revealed Patient #21 with an admission date of 7/22/09 and a discharge date of 7/27/09 had the diagnoses of Pneumonia and Chronic Obstructive Pulmonary Disease (COPD). The discharge summary, history and physical, physician orders, telephone orders, and physician progress notes were not dated and/or timed by the physician.
A medical record review conducted on 1/6/10 at 1045 revealed Patient #22 with an admission date of 7/16/09 and a discharge date of 7/20/09 had the diagnosis of Abscess Left Buttocks and Right Labia. The discharge summary, physician orders, and physician progress notes were not dated and/or timed. The H&P written by the Medical Student (MS) was not dated and timed by the physician or MS.
A medical record review conducted on 1/5/10 at 1500 revealed Patient #23 with an admission date of 10/30/09 and a discharge date of 11/1/09 had the diagnosis of Left Arm Cellulitis. The discharge summary was not dated and/or timed.
A medical record review conducted on 1/5/10 at 1430 revealed Patient #24 admitted as an observation (OBS) patient on 10/26/09 and a discharge date of 10/29/09 had a diagnosis of Pneumonia. The discharge summary, physician orders, and physician progress notes were not dated and/or timed by the NP and physician.
A medical record review conducted on 1/6/10 at 0945 revealed Patient #25 with an admission date of 7/29/09 and a discharge date of 7/31/09 had the diagnoses of Dehydration, Nausea, and Vomiting. The discharge summary was not dated and/or timed by the physician. The findings were verified by the Director of Professional Services on 1/6/10 at 1630.

On the days of the Recertification survey based on record review and interview, the facility failed to ensure an annual evaluation of its total program .

The findings included:

Review of written data and other materials revealed that the hospital had not completed a program evaluation. On 1/6/10 at 1500, the Chief Executive Officer (CEO) reported in an interview that no program evaluations could be found or provided for surveyor review. The CEO also confirmed there was no written policy pertaining to the annual program evaluation.

On the days of the Recertification survey based on recorde review and interview, the facility failed to ensure an annual evaluation of its total program to include utilization of its services .

The findings included:

Review of written data and other materials revealed that the hospital had not completed a program evaluation. On 1/6/10 at 1500, the Chief Executive Officer (CEO) reported in an interview that no program evaluations could be found or provided for surveyor review to show the hospital's utilization of services. The CEO also confirmed there was no written policy pertaining to the annual program evaluation

On the days of the Re-certification survey, based on interview, the facility failed to ensure an annual evaluation of its total program to include a representative sample of both active and closed clinical records.

The findings included:

Review of written data and other materials revealed that the hospital had not completed a program evaluation or an annual evaluation of its total program to include a representative sample of both active and closed clinical records. On 1/6/10 at 1500, the Chief Executive Officer (CEO) reported in an interview that no program evaluations could be found or provided for surveyor review. The CEO also confirmed there was no written policy pertaining to the annual program evaluation

On the days of the Re-certification survey, based on interview, the facility failed to ensure an annual evaluation of its total program to include health care policies .

The findings included:

Review of written data and other materials revealed that the hospital had not completed a program evaluation. On 1/6/10 at 1500, the Chief Executive Officer (CEO) reported in an interview that no program evaluations could be found or provided for surveyor review. The CEO also confirmed there was no written policy pertaining to the annual program evaluation or an annual evaluation of the hospital's health care policies.

On the days of the Re-certification survey, based on interview, the facility failed to ensure an annual evaluation of its total program to include to include the purpose of the evaluation .

The findings included:

Review of written data and other materials revealed that the hospital had not completed a program evaluation or an evaluation that included the purpose of the annual program evaluation. On 1/6/10 at 1500, the Chief Executive Officer (CEO) reported in an interview that no program evaluations could be found or provided for surveyor review. The CEO also confirmed there was no written policy pertaining to the annual program evaluation

On the days of the Swing Bed Recertification survey based on observation, record review , and interview, the hospital failed to ensure that Residents on the Swing bed unit received the care and services related to accurate comprehensive resident assessment, development of comprehensvie resident care plans, planned resdient activities by a qualified professional, nutirtional consults and services for identified residents, and documentation that physical therapy services were received by residents for 4 of 4 concurrent residents (Resdient #1, 2, 3, and 4) and 2 of 2 closed records of residents reviewed. (Resident #5 and 6)

The findings are:

Cross Reference to 385: The facility failed to ensure that an ongoing activities program was documented, directed by a qualified professional, and met the needs of the residents for six of six resident medical records reviewed. (Residents #1, 2, 3, 4, 5, and 6)

Cross Reference to 388: The facility failed to ensure the completion of an accurate comprehensive resident assessment for four of four open resident records reviewed (Residents #1, 2, 3, and 4) and two of two closed resident records reviewed (Residents #5 and 6).

Cross Reference to 395: The facility failed to ensure the development of a comprehensive plan to include measurable objectives and timetables to meet the identified needs for four of four open resident records reviewed (Residents #1, 2, 3, and 4) and two of two closed resident records reviewed (Residents #5 and 6).

Cross Reference to 398: The facility failed to ensure that facility services were provided by a qualified person in accordance with the resident's written plan of care.

Cross Reference to 401: The facility failed to ensure that the nutritional needs of the residents were met for one of four open medical records reviewed (Resident #1) and two of two closed medical records reviewed (Residents #5 and 6)

Cross Reference to 402: The facility failed to ensure the provision of physical therapy services for each resident to meet thee identified needs for for 4 of 4 open resident records (Resident #1, 2, 3, and 4) and 2 of 2 closed resident records reviewed (Resident #5 and 6) for care and services.

On the days of the Recertification survey based on interviews, record reviews, review of employee personnel record, review of hospital policy and procedure, the facility failed to ensure that an ongoing activities program was documented, directed by a qualified professional, and met the needs of the residents for six of six resident medical records reviewed. (Residents #1, 2, 3, 4, 5, and 6)

The findings included:

On 1/5/10 at 1000, an interview was conducted with Resident #1 identified as a swing bed patient verbalized no knowledge of activities provided for him/her at the hospital. When questioned about the Activities Calender posted on the wall of the resident's room, Resident #1 stated, "I didn't know what that was up there for".

On 1/5/10 at 1025, an interview was conducted with Resident #2 identified by the hospital as a swing bed resident who stated that reading was an enjoyable activity but denied knowledge of an activities program, calendar or events offered by the hospital.

On 1/5/10 at 1400, an interview was conducted with Resident #3. When questioned about participation in activities, Resident #3 denied knowledge of the activities program nor the activities calendar that was posted on the wall in the resident's room.

Review of the monthly activity calendar for October 2009, November 2009, and December 2009, a set pattern and type of activities was planned monthly. There was no documentation in the open records reviewed of Residents #1, #2, #3, #4, and in the closed records of Residents #5, and #6 of activities provided or of any documentation regarding resident participation in the activities provided.

On 1/6/10 at 0915, a review of the employee personnel file of the Activities Coordinator included a copy of the certificate from 1978 for completion of a "36 hour course". The title of the course was not provided on the certificate. In an interview on 1/6/10 at 1145, the Activities Coordinator stated that the course was for activity directors but a copy of the course contents could not be provided or any evidence to substantiate the course title. The Activity Coordinator stated that she/he had worked in nursing care facilities and hospital during the past thirty years as the social worker and activities director but had not worked full time as an activities director. Review of the activities coordinator job description did not include the necessary required professional qualifications. On 1/6/10 at 1145, the findings were reviewed and confirmed with the Activities Coordinator.

Review of the job description for the position "Social Services Director" read, "Job Summary: The Social Services Director/Discharge Planner/Activities Coordinator is a Licensed professional who directs the Social Services Department, Patient discharge planning and activities. Job responsibilities include, but is not limited to, Psychosocial Assessment... and planning activities for swing-bed patients. Minimum Qualification: Education: Graduate from an accredited school of Social Work or related field. Complies with state and federal regulations relating to social work services and practices. Experience: Two years of experience in a health care setting, preferably a hospital. Licensure/ Certification: Licensed by the SC Board of Social Work Examine..."

Review of Policy "Patient Activities", read, ".... County Hospital will provide an ongoing program of activities for its swing bed patients. Procedure: 1. The activities program will be directed by the Hospital Social Worker. 2. The activities will be designed to meet the interest, physical, social, mental and spiritual well-being of each patient ... 4. Record patient activity participation on Patient Activity Attendance Log and overall progress in Activity Progress Notes."

On the days of the Recertification survey based on interviews, record reviews, and review of hospital policy and procedure, the facility failed to ensure the completion of an accurate comprehensive resident assessment for four of four open resident records reviewed (Residents #1, 2, 3, and 4) and two of two closed resident records reviewed (Residents #5 and 6).

The findings included:

On 1/5/10 at 1430, a review of Resident #1's open medical record revealed the fifty-one year old was admitted on 12/17/09 with diagnoses of Status post Encephalitis, Deep Vein Thromboses, Bilateral Pneumothorax and Pneumonia. The initial nursing admission assessment dated 12/17/09 failed to include complete documentation of the resident's psychosocial and discharge planning assessment. The nutritional screening score was zero on the initial nursing assessment form. The screening questions included the clinical parameter for nutritional supplement with a score of six. The initial physician orders on 12/17/09 included Ensure twice daily. The supplement was not documented in the nutritional screening score. A score of six or more would be considered at risk and a referral for a nutritional assessment by dietary should have been completed. There was no documentation of a nutrition assessment by dietary.

On 1/5/10 at 1115, a review of Resident #2's open medical record revealed the eighty-five year old was admitted on 1/2/10 following an acute inpatient hospitalization due to Pneumonia, Congestive Heart Failure, Diabetes Mellitus and Hypertension. The initial nursing assessment dated 1/2/10 did not address the patient's skin condition or educational needs. The fall risk assessment score of forty indicated a need to implement the fall risk protocol. There was no indication of implementation of the fall risk protocol as confirmed by the Director of Patient Care Services on 1/6/10 at 1445.

On 1/5/10 at 1215, a review of Resident #3's open medical record revealed the eighty-two year old was admitted on 1/1/10 with diagnoses of Anemia, generalized weakness, recent upper GI (Gastrointestinal) Bleed, Hypertension and Parkinson's disease following an acute inpatient hospitalization. The initial nursing assessment dated 1/1/10 failed to include an educational needs assessment.

On 1/5/10 at 1415, a review of Resident #4's open medical record revealed the eighty-nine year old was admitted on 1/1/10 due to weakness following an acute hospitalization for Congestive Heart Failure, Cardiomyopathy, Hypertension, and Diabetes Mellitus. The initial nursing assessment dated 1/1/10 failed to include assessment of the renal/endocrine system and advanced directives.

On 1/6/10 at at 1050, a review of Resident #5's closed medical record revealed the eighty-seven year old was admitted on 11/27/09 with diagnoses of weakness, Anemia, and Hypotension following an acute care hospitalization for severe Dehydration, Hypotension and Anemia. The resident's Hemoglobin was 9.9 on 11/30/09 and 9.8 on 12/4/09. The initial nursing assessment dated 11/27/09 did not include the patient's current medications or discharge planning. A score of six on the nutritional screening, indicated a need for a nutritional assessment by dietary. There was no documentation that a dietary referral had been requested.

On 1/6/10 at 1150, a review of Resident #6's medical record revealed the eighty-four year old was admitted on 10/15/09 with diagnoses of weakness, Depression, weight loss, and poor appetite. The initial nursing assessment dated 10/15/09 did not include a skin assessment. The nutritional screening score of 10 indicated a need for a nutritional assessment by dietary. There was no documentation that a dietary referral had been requested.
The findings were reviewed and confirmed with the Director of Patient Care Services on 1/6/10 at 1140.

Review of hospital Policy, "Swing Bed Comprehensive Assessment Policy", read, "Objective: To establish a process of obtaining necessary information to develop a care plan to provide the appropriate care and services for each patient. Policy: A comprehensive assessment will be used upon admission to assess patient needs/ functional capacity. The assessment will include: ... 10. Disease diagnoses and health condition ... 11. Dental and nutritional status 12. Skin condition ... 14. Medication 15. Discharge potential ..."

On the days of the Recertification survey based on interviews and review of employee personnel records, the facility failed to ensure the development of a comprehensive plan to include measurable objectives and timetables to meet the identified needs for four of four open resident records reviewed (Residents #1, 2, 3, and 4) and two of two closed resident records reviewed (Residents #5 and 6).

The findings included:

On 1/5/10 at 1430, a review of Resident #1's medical record revealed the fifty-one year old was admitted on 12/17/09 with diagnoses of Status Post Encephalitis, Deep Vein Thromboses (DVT), Bilateral Pneumothorax and Pneumonia. The standards of care addressed in the Interdisciplinary Plan of Care included impaired physical mobility. Nursing care plans related to discharge planning, infection, DVT and pneumonia were not addressed. On 12/17/09, initial physician orders included for physical therapy to evaluate and treat. An initial evaluation was completed by the physical therapist on 12/18/09. The plan of treatment on the initial physical therapy evaluation form included gait training, therapeutic exercises, and activities five time a week. The plan of treatment had not been signed by the physician and no verbal order authorizing the treatment plan was signed by the physician. Physical therapy services were not included in the Interdisciplinary Plan of Care. There was no documentation in the resident's record of physical therapy visits five times a week. On 1/5/10 at 1500, the director of physical therapy stated that visit notes were not completed for each visit but a weekly progress note was documented for swing bed residents. The physical therapy director confirmed that the record did not reflect individual visit notes by the physical therapist.

On 1/5/10 at 1115, a review of Resident #2's medical record revealed the eighty-five year old admitted on 1/2/10 following an acute inpatient hospitalization due to Pneumonia, Congestive Heart Failure, Diabetes Mellitus and Hypertension. The standards of care addressed in the Interdisciplinary Plan of Care only included discharge plan of care. Nursing care plans related to Hypertension, Diabetes and Congestive Heart Failure were not addressed. On 1/6/10 at 1400, the Director of Patient Care Services confirmed the finding. A "Physical Therapy Weekly Summary" form documented a start of care date of 1/4/10. Physical therapy services were not addressed in the Interdisciplinary Plan of Care. There was no documentation in the resident's record of physical therapy visits .

On 1/5/10 at 1215, a review of Resident #3's medical record revealed the eighty-two year old was admitted on 1/1/10 with diagnoses of Anemia, generalized weakness, recent upper GI (gastrointestinal) Bleed, Hypertension and Parkinson's disease following an acute inpatient hospitalization. The standards of care addressed in the Interdisciplinary Plan of Care included Anemia and discharge care plans. There were no additional care plans related to the patient's other diagnoses. An initial evaluation was completed by the physical therapist on 1/4/10. The plan of treatment on the initial physical therapy evaluation form included gait training, therapeutic exercises, and activities five time a week. The plan of treatment had not been signed by the physician, and no verbal order authorizing the treatment plan was signed by the physician. Physical therapy services were not included in the Interdisciplinary Plan of Care. There was no documentation in the resident's record of physical therapy visits five times a week.

On 1/5/10 at 1415, a review of Resident #4's open medical record revealed the eighty-nine year old was admitted on 1/1/10 due to weakness following an acute hospitalization for Congestive Heart Failure, Cardiomyopathy, Hypertension, and Diabetes Mellitus. There was no Interdisciplinary or nursing plan of care in the resident's chart. The Director of Patient Care Services stated in an interview on 1/6/10 at 1445 that a plan of care should be initiated within twenty-four hours of admission.

On 1/6/10 at at 1050, a review of Resident #5's closed medical record revealed the eighty-seven year old was admitted on 11/27/09 with diagnoses of weakness, Anemia, and Hypotension following an acute care hospitalization for severe Dehydration, Hypotension and Anemia. The initial nursing assessment dated 11/27/09 showed staff documented a score of six on the nutritional screening indicating the resident was at risk. The fall risk assessment score was sixty which indicated the patient was at risk for fall. The standards of care addressed in the Interdisciplinary Plan of Care included impaired physical mobility and discharge. There were no additional care plans related to Anemia, Hypotension, Falls, and Nutrition.

On 1/6/10 at 1150, a review of Resident #6's medical record revealed the eighty-four year old was admitted on 10/15/09 with diagnoses of weakness, Depression, weight loss, and poor appetite. The initial nursing assessment dated 10/15/09 did not include a skin assessment. The nutritional screening score of 10 indicated a need for a nutritional assessment by dietary. There was no documentation that a dietary referral had been requested. The standards of care addressed in the Interdisciplinary Plan of Care included impaired physical mobility and discharge. There were no additional care plans related to Depression, and Nutrition.

Review of hospital Policy, "Swing Bed Comprehensive Care Plan Policy", read, "Objective: To provide appropriate care and services to meet the patients medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. Policy: 1. A comprehensive care plan will be developed within seven (7) days after the completion of the comprehensive assessment on each patient. 2. The comprehensive care plan will include measurable objectives, timetable and professional intervention to meet the patient's needs and or maintain the highest practicable mental, physical and psychosocial well being. 3. An interdisciplinary team approach will be used in developing the plan of care. ..4. The plan of care will be reviewed and revised by the interdisciplinary team within thirty (30) days of the patients assessment."

On the days of the Recertification survey based on interview, record reviews, and review of employee personnel records, the facility failed to ensure that facility services were provided by a qualified person in accordance with the resident's written plan of care.

The findings included:

Cross reference C- 385: The facility failed to ensure that an ongoing activities program was provided which met the needs of the residents and directed by a qualified professional.

On the days of the Recertification survey based on interviews and record reviews, the facility failed to ensure that the nutritional needs of the residents were met for one of four open medical records reviewed (Resident #1) and two of two closed medical records reviewed (Residents #5 and 6)

The findings are:

On 1/5/10 at 1430, a review of Resident #1's medical record revealed the fifty-one year old was admitted on 12/17/09 with diagnoses of Status Post Encephalitis, Deep Vein Thromboses, bilateral Pneumothorax and Pneumonia. needs. The nutritional screening score was zero on the initial nursing assessment form. The screening questions included the clinical parameter for nutritional supplement which would rate a score of six. The initial physician orders on 12/17/09 included Ensure twice daily. The supplement was not documented in the nutritional screening score. A score of six or more would be considered at risk and a referral for a nutritional assessment by dietary should have been completed. There was no documentation of a nutrition assessment by dietary. Documentation on the graphic sheet on 1/1/10 noted the patient ate 35% at lunch and supper; 1/2/10- 30% of breakfast, 5% lunch, and 25% supper; and 1/3/10- 50% breakfast, lunch and supper. The patient's Hemoglobin on 1/3/10 was 9.5 g/dL; 9.1 g/dL on 1/4/10; and 8.8 g/dL on 1/5/10. The patient's height was 5'6" and weight was 130 pounds. There was still no documentation of a nutritional referral or assessment on the patient's record.

On 1/6/10 at at 1050, a review of Resident #5's closed medical record revealed the eighty-seven year old was admitted on 11/27/09 with diagnoses of weakness, Anemia, and Hypotension following an acute care hospitalization for severe Dehydration, Hypotension and Anemia. The resident's Hemoglobin was 9.9 on 11/30/09 and 9.8 on 12/4/09. The initial nursing assessment dated 11/27/09 showed staff documented a score of six on the nutritional screening which indicated a need for a nutritional assessment of the patient by dietary. There was no documentation that a dietary referral had been requested or completed.

On 1/6/10 at 1150, a review of Resident #6's medical record revealed the eighty-four year old was admitted on 10/15/09 with diagnoses of weakness, Depression, weight loss, and poor appetite. The initial nursing assessment dated 10/15/09 showed staff documented a score of 10 on the nutritional screening, indicating a need for a nutritional assessment by dietary. There was no documentation that a dietary referral had been requested or completed. The findings were reviewed and confirmed with the Director of Patient Care Services on 1/6/10 at 1140.

On the days of the Recertification survey based on interviews, and review of employee personnel records, the facility failed to ensure the provision of physical therapy services for each resident to meet thee identified needs for 4 of 4 open resident records (Resident #1, 2, 3, and 4) and 2 of 2 closed resident records reviewed (Resident #5 and 6) for care and services.

The findings included:

On 1/5/10 at 1430, a review of Resident #1's medical record revealed the fifty-one year old was admitted on 12/17/09 with diagnoses of Status post Encephalitis, Deep Vein Thromboses, bilateral Pneumothorax and Pneumonia. On 12/17/09, initial physician orders included for physical therapy to evaluate and treat. An initial evaluation was completed by the physical therapist on 12/18/09. The plan of treatment identified by the therapist included gait training, therapeutic exercises, and activities five times a week. The plan of treatment had not been signed by the physician and no verbal order authorizing the treatment plan was signed by the physician. Physical therapy services were not included in the Interdisciplinary Plan of Care. There was no documentation in the resident's record of physical therapy visits .


On 1/5/10 at 1115, a review of Resident #2's medical record revealed the eighty-five year old was admitted on 1/2/10 following an acute inpatient hospitalization due to Pneumonia, Congestive Heart Failure, Diabetes Mellitus and Hypertension. A "Physical Therapy Weekly Summary" form documented a start of care date of 1/4/09. Physical therapy services were not addressed in the Interdisciplinary Plan of Care. There was no documentation in the resident's record of physical therapy visits .

On 1/5/10 at 1215, a review of Resident #3's medical record revealed the eighty-two year old was admitted on 1/1/10 with diagnoses of Anemia, generalized weakness, recent upper GI (gastrointestinal) Bleed, Hypertension and Parkinson's disease following an acute inpatient hospitalization. An initial evaluation was completed by the physical therapist on 1/4/10. The plan of treatment on the initial physical therapy evaluation form included gait training, therapeutic exercises and activities five times a week. The plan of treatment had not been signed by the physician and no verbal order authorizing the treatment plan was signed by the physician. Physical therapy services were not included in the Interdisciplinary Plan of Care. There was no documentation in the resident's record of physical therapy visits .

On 1/5/10 at 1415, a review of Resident #4's open medical record revealed the eighty-nine year old was admitted on 1/1/10 due to weakness following an acute hospitalization for Congestive Heart Failure, Cardiomyopathy, Hypertension, and Diabetes Mellitus. An initial evaluation was completed by the physical therapist on 1/1/10. The plan of treatment on the initial physical therapy evaluation form included gait training, therapeutic exercises and activities, and neuromuscular re-education five times a week. The plan of treatment had not been signed by the physician and no verbal order authorizing the treatment plan was signed by the physician. Physical therapy services were not included in the Interdisciplinary Plan of Care. There was no documentation in the resident's record of physical therapy visits .

On 1/6/10 at at 1050, a review of Resident #5's closed medical record revealed the eighty-seven year old was admitted on 11/27/09 with diagnoses of weakness, Anemia, and Hypotension following an acute care hospitalization for severe Dehydration, Hypotension and Anemia. Physician orders upon admission, dated 11/27/09, included physical therapy for strengthening and ambulation. An initial evaluation was completed by the physical therapist on 11/30/09. The plan of treatment, on the initial physical therapy evaluation form, included gait training, and therapeutic exercises and activities with a recommended frequency of five times a week. The plan of treatment was signed by the physician on 11/28/09, prior to the physical therapy evaluation. There was no documentation in the resident's record of physical therapy visits.

On 1/6/10 at 1150, a review of Resident #6's medical record revealed the eighty-four year old was admitted on 10/15/09 with diagnoses of weakness, Depression, weight loss, and poor appetite. Physician orders upon admission dated 10/15/09 included physical therapy for strengthening and ambulation. An initial evaluation was completed by the physical therapist on 10/14/09 prior to the date of the swing bed admission. The plan of treatment on the initial physical therapy evaluation form included gait training, therapeutic exercises, and activities, and modalities as indicated with a recommended frequency of five times a week. The plan of treatment was signed by the physician on 10/20/09. There was no documentation in the resident's record of physical therapy visits.